Online Application

ONLINE APPLICATION FORM FOR TEMPORARY RELOCATION

A human rights defender is any person who, individually or with others, act to promote or protect human rights including civil, political, economic, social and cultural rights. These include people working for democratic transformation in order to promote the rights to participate in the decision-making, the right to freedom of assembly, and of association etc. Human rights defenders may include judges, lawyers, journalists, bloggers, human rights monitors, peace officers / builders, etc.

Important notice: THE DEFINITION DOES NOT INCLUDE INDIVIDUALS OR GROUPS WHO COMMIT OR PROPAGATE VIOLENCE. YOU DO NOT NEED TO FILL OUT THIS FORM IF YOU DEFEND HUMAN RIGHTS BY VIOLENCE!

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1 Quick Check Questions

2 Personal Details

3 References

4 Contact Person

Where do you want to be relocated? (Select One)

Tanzania.Benin.

Are you a human rights defender as above-defined?

YesNo

Are you threatened or under intense pressure because of your work and do you think that temporary shelter and rest can help you to continue your struggle to protect and promote human rights?

YesNo

Are you ready to return to your country after three months of temporary relocation?

YesNo

If your answer is YES for all the three questions, please complete and submit the form. We will contact you as soon as we receive your application.

Full NameAs written in your passport or ID card

Date of Birth

Organization

Address

Country of Origin

Country of residence (if different):

Email Address

Phone NumberWith Country Code Please!

Skype IDIf Available

Your Passport Photo

Click Me to Upload

Description of the human rights activities of the proposed Human Rights DefenderPlease attach links to website or press articles when applicable

0 / 600

Description of the security context or risks/threats that prompted the request, any other relevant informationPlease attach links to website or press articles when applicable

0 / 600

What are the expected impact and results?

0 / 600

Please provide phone numbers as they are of particular relevance for referencing purposes and to speed the process

Reference who should be contacted to support or endorse your request

Please provide phone numbers as they are of particular relevance for referencing purposes and to speed the process

Reference 1 - Full NameAs written in your passport or ID card

Organization

Email Address

Phone NumberWith Country Code Please!

Skype IDIf Available

Reference 2 - Full NameAs written in your passport or ID card

Organization

Email Address

Phone NumberWith Country Code Please!

Skype IDIf Available

Direct contact person. This is may be your family member or any other close relative / friend who will be contacted in case of emergency.

Full NameAs written in your passport or ID card

Country of Residence

Email AddressEnter a Valid Email

Phone NumberWith Country Code Please!