(eng) application form cso outreach for hlp meeting final

APPLICATION FORM

CSO Outreach: High Level Panel (HLP) meeting on the Post-2015 Development Agenda

Bali – Indonesia, 24th-25th March 2013

Deadline: 26 February, 4 pm Jakarta Time

A. Personal Information1. First and Middle Name: 2. Family/Last Name: 3. Sex :

a. Male b. Female4. Name of the organization you are representing:

5. Type of organizationa. NGO b. INGO

c. CBO d. National network/coalition

e. International network/coalition

f. Disability organization

g. Faith based organization h. Women’s organization

i. Indigenous organization j. Community organization

k. Others (please specify)

6. Your position or job title:

7. Address:

8. Country: City: 9. Telephone Number(/s) including Country Code: 10. Email Address: 11. Website:

APPLICATION FORM




B. Financing and SponsorshipWe encourage as many organizations as possible to cover their participation costs since financial support is limited.12. Are you fully self-financing (including flights, accommodation, meals,

airport pickup/drop off) a. Yes b. No13. Are you partial self-financing? Please specify areas where you may

require support.

14. Do you require full support? a. Yes b. NoC. Special Needs15. Do you require a visa to Indonesia?

a. Yes b. No

If yes, please provide the following details:Full name (as it appears on your passport): Passport No: Country of Issue: Date of Issue: Expiry Date: 16. The majority of the meeting will be held in English. Do you require

translation?a. Yes b. No

If yes, please specify which language from:17. Special dietary requirements:18. Please indicate any other support you may require:

APPLICATION FORM




D. Please answer the following questions in 50 words or less:NB: Selection of participants will be made based on your written responses taking into account the need to ensure gender, diversity, geographical and thematic balance etc.

a. What is the purpose of your participation at this consultation meeting?

b. Please describe your organization’s or your own work and expertise in the thematic areas and the post-2015 process.

c. How do you intend to disseminate and implement the outcomes of the Bali CSO meeting to a wider audience at national and/or regional levels?

d. Which constituency does your organization represent?

Thank you for your interest in participating in the HLP CSO meeting in Bali.Please do not confirm flights until you have received an official

invitation.Selected participants will informed by 28th February 2013

Please send the completed application form by email to:[email protected]

N o later than 4 pm Jakarta Time (GMT+7) Tuesday , 26 th February 2013

(eng) application form cso outreach for hlp meeting final

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