Annex 1

EQUIPMENT TRANSFER PROGRAMME

Equipment Transfer Application Form for OPCW Financial Support

  1. Applications for direct OPCW support are to be made on this form. Before completing the form, please read the guidelines presented in the accompanying Note by the Secretariat to confirm your eligibility for financial support under the programme.
  2. Applications may be made at any time.
  3. The applicant institution should complete this form, and send it to either the appropriate National Authority, or the Permanent Representation to the OPCW in The Hague, requesting that section 7 be completed.

(iv) The National Authority, or the Permanent Representation to the OPCW, should then submit the completed form to the International Cooperation Branch, International Cooperation and Assistance Division, OPCW, Johan de Wittlaan 32, NL-2517 JR The Hague, the Netherlands.

1. Applicant institution (Please attach the most recent annual report or equivalent)

1. Name of institution ....................................................................................................…...........………………….

2. Type: o University o Research institute o Laboratory o Other (please specify)

………………………………………………………………………………………………………………………

3. State whether the institution is supported by: o Government funding o Private funding o Both

4. Brief description of the activities of the institution:

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5. Total number of employees: full time: ...........part time: ...............

6. Contact person:……………………………………………………………………………………...….…...……

7. Position within the institution……………………………………………………………………………………

8. Address: …………………………………………………………………………………..………………….…..

9. Telephone no.:.................................................................................................................…………………....…...

10. Fax no.:..................................................................................................................................…………………...

11. E-mail address:......................................................................................................................……………....…..

12. Web-site address:…………………………………………………………………………………………….…

2. Equipment requested

1. Please provide descriptions and technical specifications in as much detail as possible:

…………………………………………………………………………………………………………………………

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2. Is any special training needed for the proper use of the equipment? If so, how is it to be arranged?

………………………………………………………………………….…………………………………………...

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3. Intended use of the equipment:

………………………………………………………………………………………………………………………

3. Donor institution (if more than one, please add extra pages as needed):

1. Name of institution .................................................................................................…...........…………………..

2. Type:

o University o Research institute o Laboratory o Other (please specify)

……………………………………………………………………………………………………………..............…

3. State whether the institution is supported by: o Government funding o Private funding o Both

4. Contact person:……………………………………………………………………………………….………….

5. Position within the institution…………………………………………………………………...……….…….

6. Address: ………………………………………………………………………………...………………….…….

7. Telephone no.:.................................................................................................................………………….......…

8. Fax no.:..................................................................................................................................…………………......

9. E-mail address:......................................................................................................................……………...…..…

10. Web-site address:…………………………………………………………………………………………….

4. Estimate of transfer costs

Please break down by freight, insurance, cost of training (if any).

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5. Documents

Please attach all documents as specified in subparagraphs 4.1 and 5.2 of the Note

(i.e. quotations and completed application forms).

6. Signature

Head of applicant institution ………………………………………………………………………………………………….

Name: ......................................................

Date: ........................................................

7. Comments/Recommendation by National Authority

Signed: .............................................................................

Name: ............................................................................... Date: ..............................................

Stamp