data  przyjęcia wniosku

WNIOSEK NR.........
O DOFINANSOWANIE PROJEKTU WYDAWNICZEGO
Z BUDŻETU GMINY ...................
do rozpatrzenia w.............kwartale...................roku
`
1. Nazwa instytucji (lub imię i nazwisko)................................................................................................
.....................................................................................................................................................................................................................................................................................................................................

2.Adres......................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
tel./fax........................................................................................................................................................  osoba prowadząca projekt........................................................................................................................

3. Nr konta................................................................................................................................................

4. Tytuł wydawnictwa..............................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

5. Termin ukazania się wydawnictwa.....................................................................................................
..................................................................................................................................................................

6. Całkowity koszt  wydawnictwa............................................................................................................
	słownie.........................................................................................................		.....................................................................................................................

7. Wysokość oczekiwanego dofinansowania  z budżetu Gminy..............................................................
	słownie.........................................................................................................
				.....................................................................................................................

8. Autor wydawnictwa..............................................................................................................................
......................................................................................................................................................................................................................................................................................................................................

9. Informacja o autorze............................................................................................................................
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

10. Zwięzły opis (konspekt) projektowanego wydawnictwa....................................................................
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

11. Do kogo adresowane jest wydawnictwo.............................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

12. Objętość (ilość arkuszy wydawniczych).............................................................................................
...................................................................................................................................................................

13. Nakład.................................................................................................................................................
...................................................................................................................................................................

14. Cena  sprzedaży jednego egzemplarza w wydawnictwie...................................................................
...................................................................................................................................................................

15. Sposoby promocji ( bardzo szczegółowo), jaka suma przewidywana jest na promocję, jak prowadzony będzie kolportaż..................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................
16. Partnerzy współuczestniczący w realizacji wydawnictwa.................................................................
..................................................................................................................................................................
...................................................................................................................................................................
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

17. Szczegółowy preliminarz wydatków
	wynagrodzenia				...................................................................................
	tłumaczenie					...................................................................................
	aranżacje					...................................................................................
	skład						...................................................................................
	studio						...................................................................................
	wyciągi barwne				...................................................................................
	przygotowanie do druku			...................................................................................
	nagrania					...................................................................................
	papier						...................................................................................
	montaż, obróbka materiału			...................................................................................
	usługi poligraficzne				...................................................................................
	tłoczenie					...................................................................................
	reklama, promocja				...................................................................................
	koszty administracyjne ( nie mogą przekroczyć 10 %) ...............................................................
	inne.................................................................................................................................................
	........................................................................................................................................................
	........................................................................................................................................................
	........................................................................................................................................................	........................................................................................................................................................
					Razem...............................................................................................

18. Źrodła finansowania projektu
•	środki  własne.......................................................................................................................................
•	dochody uzyskane z realizacji projektu			ogółem.................................................
	w tym:
	 - sprzedaż				...............................................................................................
	 - inne					...............................................................................................
•	sponsorzy komercyjni...........................................................................................................................
...................................................................................................................................................................
•	sponsorzy niekomercyjni (instytucje, fundacje)..................................................................................
...................................................................................................................................................................
•	inne.......................................................................................................................................................
	........................................................................................................................................................
	........................................................................................................................................................
	........................................................................................................................................................
				Razem..........................................................................................................

19. Do kogo należą prawa autorskie........................................................................................................
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

20. Dodatkowe uwagi i  informacje..........................................................................................................
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

..............................................................				............................................................
      podpis głównego księgowego						      podpis kierownika 
									              jednostki organizacyjnej

..................., dnia...........................................................................

Uwaga! Przy wydawnictwach zwartych konieczne jest dołączenie dwóch recenzji zewnętrznych.

16..Decyzja Komisji ds. Projektów Kulturalnych
.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

..................., dnia............................................................