APPLICATION FORM ORGANISATION AND ACTIVITIES Family name of applicant * First name of applicant * Name of organisation * Function in the organisation * Select your area of expertise Disarmament and arms controlHuman rightsHealthEnvironmentDevelopmentHumanitarian response What activities relating to humanitarian and disarmament objectives have you undertaken in the past 2 years? (Max. 200 words) * Maximum words allowed: 200. Total words: 0 What campaign activities are you planning in the run up to the conference, including in which region and countries? (Max. 200 words) * Maximum words allowed: 200. Total words: 0 If you are attending the Nayarit conference, how do you plan to follow up after the conference in your country and region? If your organisation is not a partner of ICAN, would you like to receive additional information about becoming an ICAN partner? * YesNo PERSONAL DETAILS OF APPLICANT Country of residence * Nationality * Passport number * Passport expiry date (mm/dd/yyyy) * Gender * MF Date of birth (mm/dd/yyyy) * Phone number (with country code) * Email * Address * Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip Code Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombi Comoros Congo (Brazzaville) Congo Costa Rica Cote d\’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor Timur) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepa Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Country Do you need a visa to enter Mexico? * YesNo Is there a Mexican diplomatic representation in your country? * YesNo Do you have any special needs that we should be aware of (e.g. dietary restrictions, physical disabilities, medial needs)? * SPONSORSHIP REQUEST ICAN is running a sponsorship programme for organisations from developing countries. Please see the DAC list of developing countries before submitting a request as only countries listed will be considered: http://www.oecd.org/dac/stats/49483614.pdf ICAN has limited funding available for sponsorship and will not be able to cover the costs of more than one participant per organisation in addition to the overall selection criteria. Participants are kindly asked to give an estimate of flight costs and other expenses in the space provided below. Participants applying for sponsorship are kindly asked to WAIT for confirmation from ICAN before making any final travel arrangements. ICAN does not assume liability for any change and cancellation fees incurred by the participant before the sponsorship has been confirmed. Upon confirmation of sponsorship, participants will receive flight options directly from ICAN’s travel agency. If you wish to book your flight locally, please send your booking and quotation to firstname.lastname@example.org after having received the flight options from the agency. Please take note that ICAN will only reimburse up to the rate offered by the agency unless agreed otherwise. If you choose an option sent by the agency, you will receive your electronic ticket by email. Do you require sponsorship to attend the conference? * YesNo Estimated airfare in USD * Total estimate for other travel costs in USD (visa, transportation in home country, etc) * Flight departing from and returning to (city, country) Leave a Reply Cancel reply You must be logged in to post a comment.