Peer Reviewer Application Form

PEER REVIEWER APPLICATION FORM

Apploication reference number(leave this blank)
assigned by the Foundation to your concept proposal

Ce formulaire peut-être rempli en Français, en Portugais ou en Anglais. This form may be completed in English, Portuguese, or French. Este formulário pode ser preenchido em Inglês, Francês ou Português.

SECTION A

PERSONAL DETAILS
First name / Last name / surname
Telepone country code / Telephone number / Fax nunber
Mobile number / Email address
Physical address
Postal address / City or town
In which one of the following thirteen eligible countries are you resident? Mark (X) only one option.
Angola / Botswana / Lesotho
Madagascar / Malawi / Mauritius
Mozambique / Namibia / Seychelles
South Africa / Swaziland / Zambia
Zimbabwe / Other (specify)
Are you resident in one of the 13 eligible countries? YES or NO?
What languages do you speak?
If selected as a peer reviewer, will you be available to partitipate in the regional workshop? YES or NO?
Have you applied to be a grant proposal peer reviewer for the Other Foundation before? YES or NO?
Do you have a valid passport? YES or NO?
If you do not have a valid passport, do you hany any concerns about getting one in time for the regional workshop? Please explain in no more than 50 words.

SECTION B

DECLARATION OF INTERESTS
Are you employed by, or a member of, or on the board of, or otherwise directly associated with any organizations? Please name all the organizations.
Do any of your friends, colleagues, or family members or the organizations they work with plan to submit a grant application to the Other Foundation in this round of grant making that you are applying to peer review? If so, please name the relevant individuals or organizations.

SECTION C

MOTIVATION
Why are you a great person to review grant applications for the Other Foundation? Please explain in no more than 150 words.
What do you think a good funding application should include? Please explain in no more than 100 words.
What are some of the key characteristics of initiatives that you think would work best to strengthen organizing, advocacy, or activism to adavnce the human rights, wellbeing, and social inclusion of lesbian, gay, bisexual, transgender, and intersex people in southern Africa today? Please explain very briefly in no more than 200 words.

SECTION D

DEMOGRAPHIC DATA: This section will enable us to map where and whom we are getting applications from. Responses to these questions will not prejudice your application in any way.
Where do you live? Mark (X) only one option.
Rural area / Peri-urban area / Other (specify)
Small city or town (please name the place in the space alongside, e.g. Francistown)
Township linked to major urban centre (please name the place in the space alongside, e.g. Umlazi)
Major urban centre (please name the place in the space alongside, e.g. Luanda)
In terms of sexual orientation, how do you identify yourself? Mark (X) only one option.
Straight / Heterosexual / Bisexual / Gay man
Lesbian / Asexual / Don’t know / Other (specify)
In terms of gender, how do you identify yourself? Mark (X) only one option.
Man / Woman / Gender non-conforming
Don’t know / Other (specify)
In terms of the relation between sex and gender, how do you identify yourself? Mark (X) only one option.
Cisgender / Transgender / Not applicable / Don’t know / Other

Cisgendermeans that your gender expression matches the sex that you were born with. For example, you were born female and your gender identity is that of a woman, or you were born male and your gender identity is that of a man. Transgendermeans that you do not gender identify with the sex you were born with.

In terms of your biological sex, how do you identify? Mark (X) only one option.
Male / Female / Intersex / Other
What is your age? Mark (X) only one option.
Under 25 years old / Between 25 years and 45 years old / Over 45 years old
What is your “race”? Mark (X) only one option.
Black / White / Other (specify)
What is your employment status? Mark (X) only one option.
Unemployed and looking for work / Self employed / Employed part-time
Employed full time / Full time student (not working) / Other (specify)
What are your living arrangements? Mark (X) only one option.
I live in a property that I own / I live in a property that I rent / I rent a room in a shared house
I live with my parents / I live in an informal settlement / I do not have formal housing
I live in a hosel or student accommodation / Other (specify)
Do you identify with a particular religious tradition? Mark (X) only one option.
Buddhist / African Traditional Religion / Anglican Christian
Roman Catholic Christian / Evangelical Christian / African Indigenous Church Christian
Lutheran Christian / Methodist Christian / Pentecostal Christian
Muslim / Hindu / Jewish
Orthodox Christian / No religion / Other (specify)
Do you have any special needs in terms of disability? / Yes / No / Please specify:

SECTION E

Please provide the contact details of two people who know you and your work so that we can contact them to get references.
DETAILS FOR REFERENCE 1
First name / Last name / surname
Telepone country code / Telephone number / Fax nunber
Mobile number / Email address
DETAILS FOR REFERENCE 2
First name / Last name / surname
Telepone country code / Telephone number / Fax nunber
Mobile number / Email address

SECTION F

DECLARATION
I confirm that all the information given in this application is correct. I confirm that I am submitting this application in my personal capacity. I am aware that being a peer reviewer is not a paid position at the Other Foundation. I am aware that my name and image may be shared publicly in theregular accountability reporting and public communications that the Other Foundation does about the grant making work of the Foundation. I agree that the Other Foundation can contact the referees named above to get references about me. I agree that the contact details given in this form may be added to the Other Foundation’s database of contacts for the distribution of communications from the Foundation. I have attached a copy of my curriculum vitae in submitting this application.
Full name in lieu of signature
Date / Place
NOTE: When completed, this entire form should be no longer than 4 pages. Applications that are longer than 4 pages may not be considered.

Please make sure that you submit your application by the closing date that is given on our website at . Late applications will not be accepted. You must submit your application by email to. Do not send any appendices or attachments other than this application form and your curriculum vitae. Applications submitted by fax or post or in any other way will not be accepted.