APPLICATION FORM

COURSE:

PERSONAL DATA Name: Address: Post code: Telephone nr: E-mail: Age: Citizenship: Identif. Doc. nr: Education level: English level: NTIC level: Fluent Very good Good Good Elementary Elementary Valid until: Date of birth: Town: Telephone nr (2):

Please identify any need or special requirement (about mobility, medical situation, diet, other restritions...). ...

ORGANISATION DATA Name: Address: Post Code: Telephone nr: E-mail: Type: Scope: Role: Type of contract: Duration of contract: From: to: Governmental Local Town: Fax nr: Internet address: No-governmental Regional National Other International

QUESTIONNAIRE 1. Please describe of your organisation / group / institution (activity, target-group, intervention scope, number of employees, )

2. What can you say about your network (who are your partners)?

3. What competences and specific conditions do you consider you have in order to put into practice a local based project and act as a multiplier within the framework of Clearing Participation?

4. Do you have any previous participation experience on participatory democracy local based projects? If you

answered yes, give a brief explanation about the project (theme, activities, duration, target-group) and about your role (promoter, participant, coach?

5.What is your motivation to participate on this long term training course / project?

6. What do you expect to win, at a personal and professional level, with this project?

7. In order to have an active and multiplier role within this project, you need to learn more about...

8. How do you think you will mobilize the competences and contacts you will gather through this project, even after its end?

9. In your opinion, what is participatory democracy applied to the social intervention field?

10. Please describe yourself as a learner (i.e. learning style / preferences, like based on experience, with content exposition, integrating social networks as a learning tool, etc.)

10. Please add any other information that can improve your application.

TERMS OF ACCEPTANCE Please, pay attention to the following conditions, that applies in case of being selected: 1. Commitment of participation in the whole process, including: 1.1. the careful preparation of each part of the training course, according to the coordination team requests, 1.2. the participation in the whole period of the project (18 months), 1.3. the answer to every evaluation tool or moment 2. The information about personal and organisation contacts will be shared with the other selected participants, the coordination team and with other project partners. 3. The pictures taken in training context will be used to illustrate activities in paper reports or project web pages. 4. Responsibility of your own health and safety (although the given information about any special need)

DATE, CITY AND SIGNATURE

Date and city: ________________________, _____ of _______________________ of 2011

Signature: ____________________________________________________________________________