| Name: | |
| Organization: | |
| Address: | |
| City: | |
| State/Province: | |
| Postal code: | |
| Country: | |
| Telephone: | |
| Fax: | |
| email: | |
| website: | |
| Preferred language. | English:_____ French: ____ Other: _________ (Specify) |
| I am requesting support for travel & accommodations to the 3rd International TB/HIV Workshop | Yes: _____ No:_____ |
| I do not need travel support but would like to attend. | Yes: _____ No:_____ |
| I would like to attend the Workshop but will not submit a letter of intent to OSI for a TB/HIV advocacy grant. | Yes: _____ No:_____ |
| Type of organization | (check all that apply): |
| HIV/AIDS organization | Yes: _____ No:_____ |
| TB organization | Yes: _____ No:_____ |
| Community group | Yes: _____ No:_____ |
| Community health clinic/hospital | Yes: _____ No:_____ |
| Health department | Yes: _____ No:_____ |
| Non-governmental organization (NGO) | Yes: _____ No:_____ |
| Religious organization | Yes: _____ No:_____ |
| Other | Yes: _____ No:_____ |
| None | Yes: _____ No:_____ |
| TB/HIV Workshop Applicant Information |
| Please provide the following information in two pages or less. |
- Briefly describe the type of work your group or organization does. Address the following:
- Experience/focus on HIV/AIDS and/or TB advocacy, education and mobilization;
- Experience/focus on policy change and advocacy work;
- Involvement & representation of PLWHA on board, staff and all levels;
- Responsiveness to gender equity, expertise and inclusion;
- Responsiveness to/inclusion of specific vulnerable populations (specify);
- Participation in national, regional or global PLWHA treatment activist networks (specify);
- Participation in the First or Second International TB/HIV Community Education & Mobilization Workshops;
- Participation in the International Treatment Preparedness Summit or Coalition;
- Describe relevant follow-up activities including current and planned activities.
- Why would you like to attend the TB/HIV workshop, and what do you hope to do/learn?
- What concrete activities will you do after the workshop to address the TB/HIV epidemic?
Thank you for your interest.
We will notify workshop attendees in mid-August.
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