Iraq Sanctions Challenge
39 West 14 Street, Room 206,
New York, NY 10011 (212) 633-6646

fax: (212) 633-2889 email: iacenter@iacenter.org http://www.iacenter.org/iraqchallenge/

IRAQ SANCTIONS CHALLENGE PARTICIPANT APPLICATION

NAME (as it appears on your passport) ________________________________________________

ADDRESS ______________________________________________________________________

CITY/STATE/ZIP _________________________________________________________________

HOME PHONE (     )_________________________

WORK (      )_________________________

EMAIL_________________________________

FAX( )_________________________________

DATE OF BIRTH _____________________ GENDER (M/F)
ETHNICITY __________________

PASSPORT NUMBER ______________________ EXPIRATION____________ COUNTRY

SPONSORING GROUP ____________________________________________________________

GROUP'S CONTACT PERSON ________________________
PHONE (      ) _______________

IN CASE OF EMERGENCY, CONTACT:

NAME __________________________________

RELATIONSHIP TO YOU ____________________

HOME PHONE (      ) _______________________

WORK (      ) ________________________

HEALTH: Do you have any health problems that might interfere with your participation in this Iraq Sanctions Challenge, including but not limited to allergies, disabilities, psychiatric disorders? No Yes

If yes, please explain:

MEDICAL SKILL: Excellent Good Fair None

Explain:

LANGUAGE SKILL: ARABIC Excellent Good Fair    Other languages:

PLEASE COMPLETE INFORMATION BELOW FOR TWO REFERENCES:

NAME ___________________________________

RELATION TO YOU ______________________

ADDRESS_______________________________________________________________________

CITY/STATE/ZIP__________________________________________________________________

HOME/PHONE (     ) ______________________

WORK/PHONE (     ) _________________

NAME ___________________________________ 

RELATION TO YOU ______________________

ADDRESS_______________________________________________________________________

CITY/STATE/ZIP__________________________________________________________________

HOME/PHONE (    ) ______________________

WORK/PHONE (     ) _________________

COMMUNITY, SOCIAL, POLITICAL OR RELIGIOUS ACTIVITIES

Answer the following questions as completely as possible. Type or print your answers on separate pages and attach them. Please read all of the questions before you begin to answer.

  1. Do you have experience working with groups? What skills do you bring to facilitating group interaction and cohesion?
  2. Have you been involved in Iraq solidarity work? What motivates your interest in this work?
  3. Have you been to the Middle East before? If yes, when and for what purpose?
  4. What do you think will be the most difficult part of this trip? What strengths can you call upon to deal with the stress of the trip?
  5. Why do you want to go on the Iraq Sanctions Challenge? How will you use this experience when you return to the U.S.?
  6. How will you respond if the US government tries to prevent the Iraq Sanctions Challenge from delivering its material aid?
  7. If the members of the Iraq Sanctions Challenge make a tactical or strategic decision with which you disagree, but with which you do not have a profound moral objection, how will you respond?


Read the following statement carefully, sign, and date.

I hereby certify that I have carefully read and completed this PARTICIPANT APPLICATION, and am able to be, if selected, a participant in the Iraq Sanctions Challenge. I further certify that my answers to all of the questions on this application are true and complete to the best of my knowledge.

SIGNATURE _________________________ DATE ______________________

Please send the following to the Iraq Sanctions Challenge,
39 West 14 Street, #206, New York, NY 10011
Please do not send anything via the internet

  1. PARTICIPANT APPLICATION
  2. Signed and notarized RELEASE form
  3. Photocopy of the first page of your passport
  4. Two passport photos
  5. $200 deposit

Make checks or money orders payable to Sanctions Challenge and send to:

Iraq Sanctions Challenge, 39 West 14 Street, #206, New York, NY 10011

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