CM:

EU

If you seek a partner, please fill in only the yellow marked areas

1. General Information

1.1  Acronym 					 
(Do not exceed 20 characters)

1.2  Title	(Do not exceed 120 characters)

1.3 Summary	(Do not exceed 240 characters)
	
1.4  Main       Technological Area                                                                                                
	(Choose only one)
 Medical- & Biotechnology
 Agriculture & Food Science
 Lasers
 Communications
 New Materials
 Energy Technology
	 Robotics & Production Automation
 Space
 Environment
 Transport
 Information Technology
 Other	

		Budget 
(Milions of EURO )	Duration (Months) 
From ….. to	
1.5 Budget and Duration	Definition Phase			
	Implementation Phase			
	Total			

1.6 Start Date		

	 Country	 Contribution (%)	
1.7 Country Contribution	IT:	    	
     	IL:	    	
      		    	
		    	
	     	    	
	     	    	
	     	    	
	     	    	
	     	    	

1.8 Partners Sought	 Yes                                                      No	

      Remarks	
     	

2. Project Outline

 2.1 Description (approximately one A4 page)

	

 2.2 Technological Development Envisaged

	

 2.3 Market Application and Exploitation

 	

3. Main Participant

3.1 Organisation Name	

Full Name	

Parent Organisation	

Annual Turnover (US $)
Or Annual Balance sheet		

3.2. Organisation Address / Switchboard	

Street	
	
Nr: 	

Postal Code	
	
City	

Province (Region)	
	
Country	

Telephone	
	
Fax	

3.3. Contact Person Data	

Last Name	
	
First Name	

Function	
	
Title	

Direct Telephone	
	
Fax	

E-mail	

3.4. WWW  Home Page	

3.5 Participant Identification Codes	

BSI codes	

To be filled in by the office

Nace Codes (SIC ‘92)		

Type of Organisation	__ Large Company    __ Small/Medium Size Company  __ University
__ Research Institute __ Service Provider                        __ Other	

 3.6 Contribution to the Project	

3.7 Expertise	

4. Other Participant
(If there are more”other participants”, please duplicate this page.) 	

4.1 Organisation Name	

Full Name	

Parent Organisation	
     	

Annual Turnover (US $)
Or Annual Balance sheet

4.2. Organisation Address / Switchboard	

Street	
	
Nr: 	

Postal Code	
	
City		

Province (Region)	
	
Country	

Telephone	
	
Fax	

4.3. Contact Person Data	

Last Name	
	
First Name	

Function	
	
Title	

Direct Telephone	
	
Fax	

E-mail	

4.4. WWW  Home Page	

4.5 Participant Identification Codes	

BSI codes	
To be filled in by the office

Nace Codes (SIC ‘92)		

Type of Organisation	

 4.6 Contribution to the Project	

4.7 Expertise	
     

5. Project Identification Codes	

5.1 Keywords	

	

5.2 BSI Codes	To be filled in by the office

5.3 NACE Codes (SIC’92)		

6. Relationship with Public Funded Programmes	
6.1 Is your project related      
      to any National, Regional or EU programme(s)                      	 Yes                                                      No	

      Remarks	Please elaborate:
1)	  if one/all of the involved companies previously received public funding – if yes list up  which one receive funding sources and dates.
2)	 if this or a related R&D activity is presently or has been previously supported by any public funded source. If yes. Please indicate the respective funding schemes, supporting agency, amounts and dates.	

The participants signing below intend to co-operate within the project as described in both submission forms. In addition the participants have or intend to put in place, a formal collaboration agreement.

They undertake to provide their respective national program coordinators with updates of this form whenever significant change occurs.

Co-signature of main participant 	
Organisation name	

Full Name	

Name of PERSON signing	

Last Name	
	
First Name	

Function in Organisation	

Signature
	It is not possible to sign this form electronically!	

Co-signature of other participant
(If there are more”other participants”, please find more copies of this page at the end of this document.) 
	
Organisation name

Full Name	

Name of PERSON signing

Last Name	
	
First Name	

Function in Organisation	

Signature
	It is not possible to sign this form electronically!	

Name of PERSON signing

Last Name	
	
First Name	

Function in Organisation	

Signature
	It is not possible to sign this form electronically!