APPLICATION FOR FINANCING CLINICAL ACTIVITY

Please, prepare the application for financing precisely according to the following instructions and requirements: 
•	the application must be typed legibly ( handwritten application will not be considered) 
•	when filing the application for financing, the arrangement of the questions and the space provided for the answers must stay as they are

I. GENERAL DATA	

1. Director of the clinic/Responsible person:
				(name, surname, private address, phone, e-mail)

2.Name and address of the place where clinic is situated:

3.Time limit for the realization of the project 12 months. 
4.Planned time to begin ................ to complete ...............

5.Time of the project’s commencement:	6. Time of the project’s completion:	
(gray spaces are filled by the FUPP)

7. Planned outlays (PLN)
total         ..........................	8. Granted sources (PLN)
total         ..........................	
(gray spaces are filled by the FUPP)

II. DESCRIPTION OF THE FOUNDATION’S ACTIVITY
a.	Short description of the activity, its main goals and forms of action (max. 1/2 page)

	

b.	Legal status of the clinic or the subject entitled to negotiate the contracts on behalf of the Foundation:

	

c.	List of persons rendering the services to the clinic (independently from the legal title)
No.	Name and surname	Kind of employment
(P-labor contract, Z –message, D- work contract)	
		P	Z	D	
1.						
2.						
3.						
4.						
5.						
6.						
7.						
8.						
9.						
10.						
11.						
12.						
13.						
14.						

d.	List of the students participating in the clinic’s activity:
No.	Name and Surname	Study year	
1.				
2.				
3.				
4.				
5.				
6.				
7.				
8.				
9.				
10.				
11.				
12.				
13.				
14.				
15.				
16.				
17.				
18.				
19.				
20.				

e.	List of the coordinators:
No.	Title/degree	Name and Surname	Specialization	
1.					
2.					
3.					
4.					
5.					
6.					
7.					
8.					
9.					
10.					
11.					
12.					
13.					
14.					
15.					
16.					
17.					
18.					
19.					
20.					

f.	Information about:

It is declared hereby that (write the name of the clinic):
 Fulfils the standards provided by the Foundation, which was confirmed by the Board of the Foundation
 Applies for the approval of the clinic’s activity in consistency with the Standards
 Does not apply for the approval of the clinic’s activity in consistency with the Standards

(mark the right space)

i.	Wypełnianiu standardów przewidzianych przez FUPP
Niniejszym oświadczam, że (wpisać nazwę poradni)

ii.	Numbers and the costs of the cases taken by the clinic in period of calendar year previous to the submission of the application, including the number of the closed cases

In the year  (put the year) legal clinic (put the name of the clinic) has taken (put the number of the cases) cases, including (put the number of closed cases) closed cases. Average cost of the case was (put the average cost of the case – quotient of the receipts and the number of the cases).

iii.	Number and the average cost of the cases taken by the clinic since the beginning of the calendar year in which the application is submitted, including number of the closed cases.

Since the beginning of the year (put the year) legal clinic (put the name of the clinic) has led (put the number of the cases) cases, including (put the number of closed cases) closed cases. Average cost of the case was (put the average cost of the case – quotient of the receipts and the number of the cases).

iv.	Number of the didactical hours realized by the legal clinic.

The clinic carries on didactical courses of ...... hours/academic year. (put the number of the hours) 

COST CALCULATION OF THE CLINIC’S ACTIVITY IN THE PERIOD COMPRISED BY THE APPLICATION.
1. Particular positions of the calculation given in present prices (PLN).
Position	Planned costs in the budget year	
	200...	200...	Total	
1. Salaries and the like/derived
including those from FUPP				
				
2. Office/computer equipment with the software
                 including those from FUPP				
				
3. Impermanent materials and objects
(paper, toner)
including those from FUPP				
				
4. Other services
(translations, xero)
including those from FUPP				
				
5. Foreign cooperation costs
(conferences, symposium, congresses) 
including those from FUPP				
				
6. Other direct costs
(national trips)
including those from FUPP				
				
7. Total costs 
including those from FUPP				

2. Expected financing sources.							
Categories	
Number of the sources	
Proportional participation in total cost	

Applicant’s own contribution (in cash):	

Material contribution (in present pricing):	

1.	

2. 	

3.	

Sum of the own contribution (sum of the above positions):	

Sources from other sponsors, name the sponsors:	

1.	

2.	

3.	

Applied subsidy amount from FUPP	

GENERAL COST OF THE PROJECT	

100 %	

							
	 	 	 	 	 	 	 	 	
2. List of the office/computer equipment including computer programs. Total amount ............ zł
(name the particular positions according to the given schema): 
a/ name of the object:
basic technical parameters:
planned cost .................. zł, planned time of purchase (month, year) ..............................

b/ name of the object:
basic technical parameters:
planned cost .................. zł, planned time of purchase (month, year) ..............................

3. Essential motivation for the purchase :

4. Information about the expected purchase of the impermanent materials and objects Total amount............zł
(give the expected cost of the most important groups of impermanent materials and objects)

5. Information about other, expected services. Total amount.................. zł
(give the character of the service and the motivation for its use)

6. Information about the foreign cooperation costs necessary to provide a proper activity of the clinic.
 Total amount ............ zł.
a. Planned cost of the foreign guests’ visits in the clinic ................. zł.
b. Planned foreign trips.
    (give the year, country – institution, goal of the trip, planned amount in zł)

I take cognizance of the fact, that submitting a false or incomplete information might be a reason for refusal of the application’s consideration. I commit myself to present additional information concerning the organization and activity of the clinic in time requested by the Board of the Legal Clinics Foundation.

Place and date ................................................   

Signature of the clinic’s director/the proxy..............................