UPITNIK V.5
The main aim of the Application Form is to provide information about your company in order to identify:

Compliance with the criteria for participation the company in the Small and Medium Sized
Enterprises Competitiveness Support Facility for Western Balkan, which is financed by the
EBRD and financially supported by the EU (hereinafter WeBPSSF, MSP-CSF)

The current compliance status towards national and EU standards in the field of environment, health
and safety at work, product safety and management systems.

The nature of your investment or project
These information will help us to advise you if the loan within the Project WeBPSSF, MSP-CSF is suitable for
your company and your investment and project and what is needed to proceed in order to develop an
investment plan
Please be aware that our advice will be based on the information and data provided by your company. All
data will be treated with high confidentiality and only be used for the Project WeBPSSF Competitiveness of
SMEs.
If you have any question or need assistance please contact the Project office:
WeBPSSF Srbija, GTC Avenija 19, Vladimira Popovića 38-40, 11070 Beograd
Telefon: +381(0)11 715 6940, Faks: +381(0)11 715 6900
email: info.serbia@webpssf.com
or directly advisers:
Ljiljana Brdarević, mob. 063 319 147, email: ljiljana.brdarevic@webpssf.com
Aleksandar Ložajić, mob. 063 394 575, email: aleksandar.lozajic@webpssf.rs
Massimo Bianchi, mob.+39 3459296622, email: massimo.bianchi@webpssf.com
Thank you in advance for your cooperation!
Ovaj dokument je pripremljena uz podršku Evropske unije. Za sadržaj ovog dokumenta je isključivo odgovoran konsultant na WeBPSSF projektu I
ni na koji način ne odražava stavove Evropske unije.
Aplikacija / Upitnik
1. INFORMATION ABOUT COMPANY
Name of the company
Address
Phone
Website
Contact person
Position
Phone
Mobile phone
Email
Identification number
Activity registration code
Main products and/or
services of the comp.
Brief description of the
company (structure,
markets/customers,
history etc.)
Foundation year
2. COMPLIANCE WITH EU CLASIFICATION OF SME
2.1. Number of employees and financial data of SME
The company is allowed to participate in the Project WeBPSSF Competitiveness - Serbia, Small and Medium
Sized Enterprises Competitiveness Support Facility, if it fulfills the EBRD and the EU criteria for classification
in small and medium enterprise (hereinafter SME). To prove compliance with these criteria, please provide
the following data for the year with the last audited balance (2012)
Number of employees or SME (less than 250):
Annual Turnover* of SME (maximum EUR 50 million):
Annual Balance Sheet Assets * of SME (maximum EUR 43 million):
* Note: Apply middle exchange rate of the National Bank of Serbia at 31/12/2011: 1 EUR = 113,7183 RSD
The number of employees is binding criteria for the classification of company in the SME.
With regard to financial criteria it is enough to meet only one of the two listed criteria.
strana 2 od 7
Ovaj dokument je pripremljena uz podršku Evropske unije. Za sadržaj ovog dokumenta je isključivo odgovoran konsultant na WeBPSSF projektu i
ni na koji način ne odražava stavove Evropske unije.
.
Aplikacija / Upitnik
2.2. Ownership structure of SME
• Provide a list of all owners (natural and legal entities) whose participation in the ownership is 25% or
more:
• Specify if a shareholder is a state institution or public company
• Please provide basic data on legal and/or natural entities, whose participation in the ownership is 25%
or greater (name, identification number, percentage of ownership share, number of employees, annual
turnover and balance sheet assets):
• Please provide basic data on all companies, which are in your ownership (of the company or the owner
of company) with a share of 25% or greater (name, identification number, percentage of ownership
share, number of employees, annual turnover and balance sheet assets):
3. COMPLIANCE WITH NATIONAL AND EU STANDARDS AND REGULATIONS in
environmental, health and safety and work, product safety and management
systems
3.1. Quality Management Systems
• Has the company introduced any quality management system (Yes / No)?
• If yes, please note/explain what kind of quality management system has introduced in the company
(HACCP, ISO 9000, CE mark, Eco - Labeling, GAP, GMP, accreditation of laboratories, certification
body, etc.):
• Do you plan to introduce another quality management system in the company (Yes / No, if Yes,
specify which one)?
strana 3 od 7
Ovaj dokument je pripremljena uz podršku Evropske unije. Za sadržaj ovog dokumenta je isključivo odgovoran konsultant na WeBPSSF projektu i
ni na koji način ne odražava stavove Evropske unije.
.
Aplikacija / Upitnik
3.2. Health and safety at work
• Has the company introduced ISO 18000 OHSAS system requirements (Yes / No)?
• If no, is the company ready for introduction of the OHSAS system (Yes / No)?
• Have any serious injuries at work occurred in the past, resulting in death or permanent disturbances
(Yes / No)?
• If yes, please write the number of such cases:
- number of accidents : _____
- number of deaths: _____
- number of permanent disturbances: _____
3.3. Environmental Compliance
• Has the company received complaints due to environmental pollution by:
- neighborhood (Yes / No)?
- NGOs (Yes / No)?
- other companies close the location (Yes / No)?
• Has the company been a subject of the regular environmental inspection (Yes / No)?
• If yes, please, specify the environmental problem/s identified within the Inspection Report (in area of:
waste water, solid waste, hazardous waste, exhaust gases, noise, inappropriate chemicals storage, etc)
• What kind of measures have to be undertaken by the company towards the Inspection Report/s?
• Does the SME deal with collection, transport and disposal of all kinds of solid waste (Yes / No)?
• If yes, please, identify the type of permission and its issuing authority that company has obtained?
• Does the company have obligation according the national Law on packaging management and
packaging waste (Official Gazette no. 36/2009), (Yes / No)?
• Does the company generate the hazardous waste (Yes / No)?
strana 4 od 7
Ovaj dokument je pripremljena uz podršku Evropske unije. Za sadržaj ovog dokumenta je isključivo odgovoran konsultant na WeBPSSF projektu i
ni na koji način ne odražava stavove Evropske unije.
.
Aplikacija / Upitnik
• Does the company produce the electrical and electronic equipment and devices (Yes / No)?
• Has the company introduced any of environmental management systems (Yes / No)?
• If yes, please, specify which environmental management system the company has introduced (EMAS,
ISO 14001 set of standards, cleaner production, etc.)
• If no, has the company interest in introducing any environmental management system? (Yes / No)?
4. PRELIMINARNY INVESTMENT PLAN

Has the company already prepared plan for investments to be in compliance with environmental,
safety work and health and management standards (Yes/No)?

If yes, please, provide the approximately budget for implementation of preliminary investment plan:
Planned total investment cost (EUR):
Planned loan amount (EUR):
Planned start of implementation (date):
Duration of implementation (months):
Planned start of operations/end of implementation (date):

Please provide the structure of the planned investments (an examples of specifying the structure of
investment are in the table, which you will delete and specify the structure of your investment – please
adjust the table to meet your needs to present the structure of your investment)
Estimated amount
(EUR)
Components of the investment:
1. Equipment
1.1. Example: Machine for ___, from supplier ___, which replaces an
existing machine for ____, produced ___ years.
1.2. etc.
2. Building and inastallation
2.1. Example: Construction of the ____ pursuant to the main construction
project prepared by ___
2.2. Example: Installation of mechanical installations (heating, ventilation,
cooling), pursuant to the main design of mechanical installations prepared
by ___
2.3. Example: Installation of electrical installations pursuant to the main
strana 5 od 7
Ovaj dokument je pripremljena uz podršku Evropske unije. Za sadržaj ovog dokumenta je isključivo odgovoran konsultant na WeBPSSF projektu i
ni na koji način ne odražava stavove Evropske unije.
.
Aplikacija / Upitnik
project of electrical installation prepared by ___
2.4. etc.
3. Services and other expenses
3.1. Example: introduction of ISO 9001 certification based on the offer of
supplier ___
3.2. Example: preparation of the document on risk assessment in the
workplace
3.3. etc.
TOTAL INVESTMENTS (1+2+3)

Will the product quality and safety be improved by the implementation of the investments in the
company (Yes / No)? If yes, please explain the improvements:

Will the health and safety of work be enhanced by the implementation of the investments in the
company (Yes / No)? If yes, please explain the enhancements:

Will the environmental compliance be increased by the implementation of the investments in the
company (Yes / No)? If yes, please explain the improvements:

Will the management systems be introduced or improved by the implementation of the investments in
the company (Yes / No)? If yes, please specify the management systems:
• Please provide the following information on project status:
Project is in conceptual phase (Yes / No)?
Preparation of technical design documents ongoing (Yes / No)?
Technical design documents/the main project finalized (Yes / No)?
Proforma invoices / quotations from the suppliers obtained (Yes / No)?
Permitting in progress (in progress / completed)
• Has the company interest to work with the Project Consultant in developing the Investment plan in order
to apply for the loan within the EBRD credit line (Yes / No/I do not know)? _____
• We apply for participation in the Project WeBPSSF Competitiveness - Serbia through the (specify the
bank) __________________________________________________________.
strana 6 od 7
Ovaj dokument je pripremljena uz podršku Evropske unije. Za sadržaj ovog dokumenta je isključivo odgovoran konsultant na WeBPSSF projektu i
ni na koji način ne odražava stavove Evropske unije.
.
Aplikacija / Upitnik
• We declare that we have not applied for WeBPSSF Competitiveness - Serbia through another
Participating Bank (Yes/No) ______
• We declare that we have applied for WeBPSSF through the (specify the bank)
__________________________________________________________ on ______________ and that
(our request have been rejected/ or that up to now we have not received a positive response)
_________________________________________________________.
• We hereby declare that no other EC grant support has been/is expected to be received for the above
mentioned investment project.
Date:
Authorized representative of the company
M.P.
strana 7 od 7
Ovaj dokument je pripremljena uz podršku Evropske unije. Za sadržaj ovog dokumenta je isključivo odgovoran konsultant na WeBPSSF projektu i
ni na koji način ne odražava stavove Evropske unije.
.