2016-2017 Indigenous Leaders Conservation Fellowship Application Form

Indigenous Leaders Conservation Fellowship

APPLICATION FORM

Note: Deadline for submission of this application is September 31st, 2016. Please e-mail this application to [email protected] along with:

 Your CV or resume, and a copy of your personal identification card.

 A nomination letter from your sponsoring community or indigenous/local organization, demonstrating that you have the support of the community in which you will be working.

 A 2-3 page outline of your proposed work plan, explaining your proposed area of work and outputs. Please do not go beyond 3 pages (see guide below).

 A completed budget estimate worksheet (worksheet provided below).

Part I

1. Family Name: First Name:

2. Gender:

3. Place of Birth:

4. Date of Birth:

5. Indigenous/Traditional Peoples/Nation:

6. Nationality:

7. Address:

8. Telephone:

9. E-mail: 10. Fax:

11. Best way to contact you:

Part II

1. Region you are going to work in:

2. Knowledge of languages

On a scale of 1-3, 1 being fluent; 2 being intermediate; and 3 being basic; please list the languages you know and rate your skills in that language.

LANGUAGE SPEAKING WRITING READING

3. What previous or current fellowships, scholarships or awards have you received?

4. What is the highest level of education you have achieved?

5. Do you have any connections with regional or national indigenous peoples organizations or NGOs? If yes, which ones?

6. What type of professional development opportunities would you want to participate in if you received the fellowship? I certify that the statements made by me in answer to the above questions are true, complete, and correct to the best of my abilities.

______

Signature Date

WORK PLAN PROPOSAL GUIDELINES

Please use these guidelines to help you formulate your proposed work plan. Anything longer than 3 pages will not be considered.

Project Title:

Background:

Goals:

Activities:

1. Planning stage

2. Project design

3. Project Implementation

Total estimated budget for this project:

Please fill in the timeline below:

ACTIVITY Month Month Month Month Month Month Month 1 2 3 4 5 6 7 Project Planning Phase

Project Design

Project Implementatio n

BUDGET TEMPLATE

Fill in the table according to your own proposal. In the professional development component, include specific trainings or meetings you are interested in attending, if possible. In the project component, include only general costs for needs such as travel, equipment or print materials. We do not need a complete breakdown of costs at this time. If you are selected for the fellowship, we will request more detailed information from you. If you have any match funding available, please include it in the third section of the table. Estimated Budget Professional Development Description of Activity Cost Component

Sub Total: Project Component

Sub Total: Match Funding If any match funding, include here

Sub Total: Grand Total