Application for Membership in Promote Musharikat Coalition

Individual Activists

Please complete and submit this form if you are interested in becoming a member ofa Musharikat Coalition.

Name of Applicant: ______Father’s Name: _______

Province: ______ District: ______

Education:□High School□BA□MATazkera No. ______ (Attach copy)

Gender:□Female □Male Age:□ Between 18-35 years□ 36+ years

Phone Number: ______Email: ______

Current Paid Employment:Organization: ______Title: ______

Are you an employee with the Government of Afghanistan? □Yes□No

If yes, please provide your department and title of your position below.

Ministry/Office/Department: ______Title: ______

Current or Previous Women’s Rights Activist/Volunteer Work: (Include any leadership roles you have/had)

□ CSO/NGO Name: ______□ Coalition/Network Name: ______

□Association Name: ______

Relevant Experience:

□ Women’s Political Participation / □ Economic Empowerment of Women
□ Access to Justice / □Access to Education
□ Access to Healthcare for Girls and Women / □ Fighting Violence against Women
□ Women’s Leadership Development / □ Eliminating Child Marriage
□Reducing Sexual Harassment / □ Women’s Social Participation
□Advocacy Campaign Planning and Implementation / □ Women’s Access to Information
□Media/Communication / □Community Mobilization
□Training/Curriculum Development / □Research
□Women’s Rights and Empowerment / □Gender Development
□Other related areas of interest and experience:

(Select all boxes that apply)

Please describe your relevant experience in advocating for women’s rights and empowerment and other relevant experience you would bring to the Musharikat coalition.

(Use the back of this page if you need more space.)

If you have a CV, you may attach it to help Musharikat understand your relevant experience. Note: This is Optional.

Are you currently active with or receiving support from any other USAID Promote project? □ Yes □ No

If yes, please indicate which project and brief description of your involvement/support:

□ Women in Economy

□ Women in Government

□ Women’s Leadership Development

I was recommendedto apply for membership in a Musharikat coalition by:

□ Musharikat Coalition Member
Name of Coalition: ______/ □ Musharikat Staff Member
Name: ______/ □ Musharikat Grantee
Name of Organization: ______
Other USAID Promote Project:
(Check below) / □ USAID Project (not Promote):
Name of Project: / □Donor or Donor Project (not USAID)
Name of Donor: ______
□Women in Economy
□ Women in Government / □Women’s Rights Network or Association
Name: ______/ □Afghan Government Official/Entity
Name: ______
□Women’s Leadership Development / □Became aware of Musharikat Coalitions through this membership[RC1] posting

Signature: ______ Date: _______

NOTE:Submit this completed form towith other documents required.Please be assured that all information provided will be closely held and not be shared with any other party, for any purpose,without prior consent.

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[RC1]I changed from EOI to “membership”