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ࡱ> [bjbj ΐΐg3+ Mcwww$PL7Jj(# # # """OIQIQIQIQIQIQI$KNuIw"""@""uIww# # r2J444"w# w# OI4"OI44EKG# p9#w$ 'F;INJ<J;FOq1O(KGKGOw_G""4"""""uIuIK4j"""J""""O""""""""" : Zatwierdzony przez IP 02.01.2013 MINISTERSTWO GOSPODARKI Program Operacyjny Innowacyjna Gospodarka 6. O[ priorytetowa: Polska gospodarka na rynku midzynarodowym DziaBanie 6.5 Promocja polskiej gospodarki PoddziaBanie 6.5.2 Wsparcie udziaBu przedsibiorcw w programach promocji Wniosek o dofinansowanie udziaBu w bran|owym programie promocji Data wpBynicia wniosku o dofinansowanie*:Numer wniosku o dofinansowanie*:*Rubryka wypeBniana przez instytucj, do ktrej przesyBany jest wniosek o dofinansowanie I. Informacje oglne o projekcie 1. TytuB projektu 1.1. Nazwa bran|owego programu promocji, do ktrego wnioskodawca zgBosiB udziaB 1.2. Termin realizacji bran|owego programu promocji, do ktrego wnioskodawca zgBosiB udziaB(dd/mm/rrrr)  (dd/mm/rrrr) 2. Identyfikacja rodzaju interwencjiProgram OperacyjnyInnowacyjna GospodarkaO[ Priorytetowa6. Polska gospodarka na rynku midzynarodowymDziaBanie6.5 Promocja polskiej gospodarkiPoddziaBanie6.5.2 Wsparcie udziaBu przedsibiorcw w programach promocji3. Klasyfikacja projektuKodNazwaTemat priorytetowy05 UsBugi w zakresie zaawansowanego wsparcia dla przedsibiorcw i grup przedsibiorcwForma finansowania01Pomoc bezzwrotnaObszar realizacji00Nie dotyczyDziaB gospodarki4. Zgodno[ projektu z politykami horyzontalnymi Unii Europejskiej wymienionymi w art. 16 lub17 rozporzdzenia Rady (WE) 1083/2006 WpByw projektu na polityk rwno[ci szans iniedyskryminacji ( Pozytywny ( Negatywny ( Neutralny Uzasadnienie WpByw projektu na polityk zrwnowa|onego rozwoju  ( Pozytywny ( Negatywny ( Neutralny Uzasadnienie  II. Identyfikacja Wnioskodawcy 5. Forma prawna prowadzonej dziaBalno[ci 6. Dane WnioskodawcyNazwa WnioskodawcyNIPNumer w: a) Krajowym Rejestrze Sdowymb) Ewidencji DziaBalno[ci GospodarczejWnioskodawca prowadzi dziaBalno[ na terytorium RP( tak( nieAdres siedziby: WojewdztwoPowiatGminaMiejscowo[UlicaNr budynkuNr lokaluKod pocztowyNumer telefonuNumer faksuAdres poczty elektronicznejAdres strony internetowejAdres do korespondencjiMiejscowo[Kod pocztowyUlicaNumer budynkuNumer lokalu7. Dane osoby/osb upowa|nionych przez Wnioskodawc do kontaktwImi i nazwiskoStanowiskoNumer telefonuNumer faksuAdres poczty elektronicznej8. Dane osoby/osb upowa|nionych do podpisania WnioskuImi i nazwiskoStanowiskoAdres poczty elektronicznej 9. DziaBalno[ Wnioskodawcy Kod PKD lub EKD podstawowej dziaBalno[ci Wnioskodawcy:10. Data rejestracji Wnioskodawcy  III. Informacje szczegBowe o projekcie 11. DziaBalno[ gospodarcza, ktrej dotyczy projekt Kod PKD lub EKD:Kod PKD lub EKD:Kod PKD lub EKD: 12. UdziaB przedsibiorcy w dziaBaniach promujcych przeznaczonych dla przedsibiorcw okre[lonych w bran|owym programie promocjiLiczba dziaBaD promujcych przeznaczonych dla przedsibiorcw w bran|owym programie promocjiLiczba dziaBaD promujcych przeznaczonych dla przedsibiorcw, do ktrych przedsibiorca zgBosiB udziaBUdziaB procentowy dziaBaD promujcych, do ktrych przedsibiorca zgBosiB udziaB do liczby dziaBaD promujcych przeznaczonych dla przedsibiorcw w bran|owym programie promocji% 13. Opis projektu 13.1. Opis towarw lub usBug danego rodzaju, ktre s lub bd produkowane lub sprzedawane przez przedsibiorc, ktrych dotyczy realizowany projekt 13.2. SzczegBowy opis zaplanowanych w ramach projektu dziaBaD 13.3. Uzasadnienie realizacji projektu 13.4. Opis zasobw umo|liwiajcych rozwj eksportu 13.5. UdziaB eksportu w caBkowitej sprzeda|y w roku obrotowym poprzedzajcym rok, w ktrym zostaB zBo|ony wniosek%13.6. Wnioskodawca posiada strategi rozwoju eksportuTAK ( NIE (Opis gBwnych zaBo|eD strategii (je[li dotyczy)13.7. Wnioskodawca prowadzi, wspBpracuje lub finansuje badania i rozwj produktw lub usBug, ktre s/ bd stanowiBy przedmiot eksportuTAK ( NIE (( Prowadzi wBasn dziaBalno[ B+R(WspBpracuje z jednym podmiotem prowadzcym dziaBalno[ B+R(WspBpracuje z dwoma lub wicej podmiotami prowadzcymi dziaBalno[ B+R(Finansuje dziaBalno[ B+ROpis: 13.8. UdziaB wydatkw na dziaBalno[ badawczo-rozwojow w dziaBalno[ci gospodarczej wnioskodawcy (je[li dotyczy) %Opis: 13.9. Wnioskodawca lub podmiot majcy co najmniej 51 % udziaBw lub akcji w przedsibiorstwie Wnioskodawcy posiada na produkt bdcy przedmiotem obecnego lub planowanego eksportu:(Patent na wynalazek(Prawo ochronne na wzr u|ytkowy(Prawo z rejestracji wzoru przemysBowego(Prawo z rejestracji topografii ukBadw scalonych(Prawo u|ywania oznaczenia geograficznegoOpis:13.10. Wnioskodawca posiada certyfikaty:(Akredytowany certyfikat jako[ci w przedsibiorstwie zgodny z wymaganiami normy ISO 9001 lub inne certyfikaty bran|owe zawierajce w sobie wymagania normy ISO 9001(Akredytowany certyfikat Systemu Zarzdzania BHP zgodny z wymaganiami OHSAS 18001 lub PN-N-18001(Akredytowany certyfikat Systemu Zarzdzania Zrodowiskowego zgodny z wymaganiami normy ISO 14001 lub rozporzdzeniem EMAS 14. Harmonogram rzeczowo-finansowy projektuHarmonogram realizacji projektuPlanowany termin rozpoczcia realizacji projektu(dd/mm/rrrr)Planowany termin zakoDczenia realizacji projektu(dd/mm/rrrr)3. 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