Category MEDIA Dear Applicant! Please fill in all of the questions below. All questions must be answered in either English, French or German. Please submit this form no later than 2 April 207 to dialog@bmeia.gv.at. When submitting your application, please make sure to indicate "Application IAA Country of Application" in the subject heading of your e-mail. Our team wishes you the best of luck! A. General Information () Applicant Information Surname Given Name Street and Number Postal Code and City Province/Country Telephone (incl. country code, i. e. +43) E-mail Applicant s position within the organisation
2 (2) The Organisation (if applicable) Name of the organisation Main field of action Established (dd/mm/yyyy) Location (street, number, city) Type of Organisation DrDop No. of employees No. of volunteers Website (if applicable) How did you hear about this award? (optional) Name of Managing Director (3) Information on the media contribution Title/Name of the media contribution You are active in intercultural work. Please specify the focus of the project. Media/Journalism Art/Culture Youth Women Global Citizenship Education Integration Form of the media contribution Type of medium used Medium operative since (dd/mm/yyyy) (if applicable) Date and place of publication Web link to the media contribution (if applicable) 2 Only media contributions published since January 206 are eligible to apply. 2 If the media contribution is not available online, please submit the published item electronically together with this form (for files larger than 8 MB, please use the file transfer tool WeTransfer (www.wetransfer.com). In case you wish to send a compressed file, kindly send only zip files (no 7-zip, RAR files etc.).
3 (4) Project Information Please answer the following questions in a concise manner. Please do not exceed the given limits. Only complete applications are eligible.. Describe the media contribution/platform in one sentence. (max. 200 characters) 2. Explain how your media contribution/platform promotes intercultural dialogue. What is your concept of intercultural dialogue? (max.,000 characters) 3. Describe the target group. (max.,300 characters)
4 4. Describe the context in which the media contribution/platform was launched. What does the contribution aim to solve? What challenges are addressed? (max. 2,000 characters) 5. Describe the impact of your media contribution/platform and how it was achieved. Please provide information showing the project s impact. (max.,300 characters)
5 6. Has your action encountered any problems? If so, please describe them. (max.,300 characters) 7. Describe supporters and partners of the project as well as the form and duration of the cooperation. Please distinguish between sponsors providing financial support and local partners providing support during implementation. (max.,300 characters)
6 8. How would you use the prize money? (max. 650 characters) 9. Why should your media contribution/platform be selected as a winner of this award? (max. 650 characters) 0. Additional remarks (max.,000 characters). You may enclose 2 pictures to this application. (optional)
7 B. Declaration of consent I hereby confirm that the information provided in this application is accurate and true. I hereby confirm that the applying organisation fulfills the local legal requirements and conditions and thus holds the right to operate the project submitted to this competition. I hereby declare that I am authorised to submit this application on behalf of the respective organisation. I hereby agree that the information provided in this application may be used by the Austrian Federal Ministry for Europe, Integration and Foreign Affairs (MFA), by Austrian representations as well as by cooperation partners to promote the project and its participants through social media and informational material. In case of selection for a prize, I consent that information relating to myself, the project and the organisation may be published on the website of the Austrian Federal Ministry for Europe, Integration and Foreign Affairs (MFA) at www.bmeia.gv.at as well as by other digital and print media outlets, including cooperative partners. My consent to the use of information provided by me can be retracted at any time and will be considered as a withdrawal from the contest. Please contact dialog@bmeia.gv.at for further information. Information will be used for the above mentioned activities only. The transfer of information to third parties, other than cooperative partners, will not be undertaken without prior approval from the applicant. Please make sure that you have filled in all relevant information before signing and submitting your application. Please also note that in case of pre-selection, you will be asked for additional documentation (i. e. license, business plan, mid-term or final project report, evaluation report, samples of media coverage etc.) Please submit your complete application no later than 2 April 207! If you experience any technical difficulties, please contact us. Please indicate the country of origin of the project/organisation or the country which you are applying from: Date (dd/mm/yyyy) Signature