AIDS 2014 International Community Partners: PWN, GNP+, ICW, ICASO, SIDACTION AIDS 2014 Programme Committee and

Track-Co-chair Nominations November 2012

NOMINATION FORM
Programme Committee Member XX International AIDS Conference (AIDS2014)
INSTRUCTIONS FOR FILLING OUT THE FORM 1. Once the form is open in Word format, save it in your computer (make sure that it is saved as .doc); 2. Read the form carefully; 3. The form is in English and you MUST fill it out electronically in English; 4. Save the form once you finish and send it as a Microsoft Word attachment to aids2014committees@icaso.org by November 15, 2012.
Incomplete applications, and applications received after the deadline will not be considered.

All fields must be completed

Family name Nationality First name Gender Female Male Transgender Country of residence Position title Title :

Affiliation: present main organization

Contact numbers: E-mail address Postal address

Tel. (Direct landline incl. country code)

Tel. (Mobile incl. country code)

E-mail address (alternative/assistant)

AIDS 2014 International Community Partners: PWN, GNP+, ICW, ICASO, SIDACTION AIDS 2014 Programme Committee and Track-Co-chair Nominations November 2012

Please indicate which committee the nominee is interested in:

Community Programme Committee Leadership & Accountability Programme Committee Scientific Programme Committee Track Co-Chair A, B, C, D, E (Please circle no more

than two) Scientific Track Committee A, B, C, D, E (Please circle no more than two)

Please complete all of the following: 1. Are you openly living with HIV? Yes No

2. Are you fluent in English? Yes No

3. Have you previously attended an International AIDS Conference (IAC)? Yes No If yes, how many: ______________ 4. Are you available for all travel and work commitments associated with the programme committees? Yes No

Its required to provide a letter from your organization stating that they have agreed for you to commit the necessary time (see info note) for the programme committee work and related travel. Without this letter no application would be considered. 5. If you have previously been a member or co-chair of an IAC programme committee, indicate which one: Community Programme Committee: Leadership Programme Committee: Scientific Programme Committee: Member Member Member Co-chair Co-chair Co-chair

6. Which of these sectors/groups do you and the organizations you are related to identify with? (check all that apply) People living with HIV Young people Labour Children Academia Women Faith-based Indigenous people Disabled persons Human rights Older persons CBO 2

AIDS 2014 International Community Partners: PWN, GNP+, ICW, ICASO, SIDACTION AIDS 2014 Programme Committee and Track-Co-chair Nominations November 2012

Business/private sector Advocacy/campaigning Sex Workers People who use drugs

Service provider NGO Foundations Transgender Men who have sex with men Other: ________________

7. At which level do the organizations you relate to operate? (check all that apply) International National Regional (multi-country) Local/Grassroots

9. What HIV-related issues are you focused on? (check all that apply) Prevention Treatment Care and support Human rights Migration and mobility Policy Harm reduction Drug policy Stigma and discrimination TB Health systems AIDS financing Research and development People Living with HIV Women and girls Sex workers Men who have sex with men Transgendered people Indigenous People Drug users Children Older people/ageing Accountability Trade Workplace Other:__________________

8. Briefly describe what knowledge, expertise, and experience (including length of time) you would bring to the programme development of the conference (maximum 100 words):

10. Describe your experience in leading the program development and in facilitation and management of a team of diverse people (maximum 100 words):

Please provide the name and contact details of two people who can be contacted as referees if needed.

1.

2.
Contact details should include: organization, position, city, country, phone and email