Company / Organization

Address

Locality

Country

Contact Person Name

Contact Person Surname

Designation

ID Card No

Email

Phone

VAT Number AND/OR Company Registration Number

Brief description of work placement

Number of available work placement

Data Protection Authorisation

Consent to the processing of personal data art. 4 (11), art. 6 and art. 7 of EU Regulation 679/2016 - GDPR

Declaration

I hereby declare that by submitting this application, I am hereby giving my consent for the publication of information related to our participation in Intercept Project.

I declare that all the information provided in this form and any other documents enclosed are, to the best of my knowledge and belief, correct. I acknowledge that the application may be subject to regular monitoring and auditing and as a Work Placement Provider I will keep adequate records for this purpose in line with instructions provided.

I hereby declare that the Work Placement provided to the Intercept Project participant will not be simultaneously supported through other funding.

I also declare that I will abide by the principle of good governance. I understand that if the information in the form is found to be not factually correct, the application may be rejected.