Expression of interest form Expression of Interest UNITED Conference - Bratislava, Slovakia - November 2019 By submitting this form your organisation nominates a candidate to participate in the upcoming UNITED conference near Bratislava, Slovakia. Please find information about the conference under Upcoming Conference and read the Conference Financial Conditions. The deadline for nomination is 15 September 2019. Only forms filled in English language will be considered. Please use Latin alphabet only. Please note that sending this nomination form to UNITED does not guarantee that you will be selected for the conference. Only selected candidates will be informed about the result of the selection and receive further information via e-mail soon after the deadline. After submitting this form you will get a notification by email. Which organisation is nominating?Organisation's name*Organisation's name in English*Abbreviation of the organisation nameAddress of the organisation* Organisation Street Address + Number Organisation City Organisation Postal Code AlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia-HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreat-BritainGreeceHungaryIcelandIrelandItalyKazakhstanKosovoKyrgyzstanLatviaLiechtensteinLithuaniaLuxembourgMacedonia - Rep. ofMaltaMoldova - Rep. ofMonacoMontenegroNagorno-KarabakhNetherlandsNorthern IrelandNorwayPolandPortugalRomaniaRussiaSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTurkeyUkraineUzbekistan Organisation Country Phone number of the organisation*Please include the country code.Mobile phone number of the organisationPlease, add country code.Fax number of the organisationPlease, add country codeEmail address of the organisation* Website of the organisation Facebook page of the organisation Twitter handle of the organisationPlease describe the work of your organisation (Max 15 lines)*Indicate the field(s) of your organisation's activity:* Anti-nationalism Anti-racism Anti-fascism Hate crime/ victim support Migrant rights Minority rights Refugee support Roma issues Trafficking LGBT Reconcilliation Anti-discrimination Human rights Intercultural Youth Work Other field Select the relevant field(s).Other field of activity* Add more fields here if you can't classify your activity into one or more field(s) which are mentioned above.Who is being nominated?Name of the nominee* Nominee First Name Nominee Last Name Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleOther GenderPlease, specify other gender:Private email address of the nominee Email address to send conference documents* Personal phone number of the delegate*Please include the country code.Personal mobile phone number of the delegate*Where you can be reached in emergencies. Please include the country code.Do you have any special requirements (vegetarian, no pork, allergies, disabilities etc.)*No.Yes.Please, specify special requirements:*Do you consider yourself to be part of a minority?*No.Yes.Please, specify minority:Have you personally experienced racism and/or discrimination?*No.Yes.Please, describe your experienceWhat languages can you work with?*MotivationPlease explain your motivation and aims for participating related to the conference's topics:*Please describe your working experiences and skills related to the conference's aims:*Describe your skills (such as leading a working group, reporting, ...) that you could offer to the conference organisers:*VISACitizenship*Will you need to apply for visa?*Yes.No.Please attach a copy of your passport:*Full name (as it is written in the passport)* First Last Private address of the delegate* Street Address + Number City ZIP / Postal Code AlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia-HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreat-BritainGreeceHungaryIcelandIrelandItalyKazakhstanKosovoKyrgyzstanLatviaLiechtensteinLithuaniaLuxembourgMacedonia - Rep. ofMaltaMoldova - Rep. ofMonacoMontenegroNagorno-KarabakhNetherlandsNorthern IrelandNorwayPolandPortugalRomaniaRussiaSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTurkeyUkraineUzbekistan Country Name to send the visa documents (invitation and hotel confirmation) to (if different from above)* First Last Address to send the visa documents (invitation and hotel confirmation) to (if different from above)* Street Address + Number City State / Province / Region ZIP / Postal Code AlbaniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French Part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch Part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsVirgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Place of birth*Country of birthAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePassport number*Passport valid until:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Details of the consulate where you will apply for visaDo you know which consulate you should approach?*Yes.No.Consulate of*In city, country*Fax Consulate*Phone Consulate*Please, add country code.Email Consulate* I agree with the financial conference conditions.* I agree. View conditions here.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Share this:FacebookTwitterGooglePinterestLinkedInRedditPress ThisEmailPrint
