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/
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 U.S. 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 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 14th Street, #206, New York, NY 10011
1. PARTICIPANT APPLICATION
2. Signed and notarized RELEASE form
3. Photocopy of the
first page of your passport
4. Four passport photos
5. $200 deposit.
Make checks or money orders payable to Global Aid and Solidarity and send to:
Iraq Sanctions Challenge, 39 West 14th Street, #206, New York, NY 10011
Applications are due December 8, 1999.
You will be notified by December 13, 1999.
The total cost of the trip will be $1,800 (the deposit is a part of this). Full
payment is due December 20, 1999.
Back to IAC Iraq Sanctions Challenge Homepage