VIVA PALESTINA INTERNATIONAL CONVOY REGISTRATION FORM

Already registered but still need to pay? Enter your email address below:

Before completing the registration form, please read over the convoy details.

Please complete fully before submitting. All fields are required.

Contact

Please enter your full legal name as it appears on your passport.

Convoy:

First Name:

Middle Name:

Last Name:

Address (line 1):

Address (line 2):

City:

State:

Country:

Zip / Postal Code:

Phone:

Email:

Confirm email address:

Emergency Contact Name:

Emergency Contact Phone:

Emergency Contact Relationship:

Registration

Please include passport information as it appears on your current passport.
Note, also, passports must be valid at the time of registration and preferably at least 6 months from expiring.

Do you agree to the Convoy Conditions? Yes
No

Gender: Male
Female

Age:

Date of Birth:

Nationality:

Passport Number:

Country Issuing Passport:

Passport Issue Date:

Passport Expiration Date:

Ever denied entry to any country? Yes
No

Date Denied Entry:

Country Denied Entry:

Details:

Joining convoy at EXACTLY which City?

Country:

Date Joining Convoy:

Will you be bringing a vehicle to drive and donate? Yes
No

Have you registered your vehicle with Viva Palestina UK? Yes
No

Note: Applicants from the United States will only be allowed to join the convoy in LONDON on Dec. 5th or ISTANBUL on Dec. 15th.

Skills

Languages spoken and level of fluency:

Special skills/expertise to share:

Any issues/commitments that might prevent you from joining or completing the convoy for the full tour? Please explain:

Previous experience in Conflict Areas/War Zones? Yes
No

If yes, explain:

Previous experience in Humanitarian Relief? Yes
No

If yes, explain:

Previous experience in Arab or Muslim Countries? Yes
No

If yes, explain:

Previous experience in Gaza specifically? Yes
No

If yes, explain:

In no more than 200 words, describe why you want to join the VIVA PALESTINA Convoy to Gaza:

Are you willing to share your experience upon returning and how do you foresee doing so?

Organizing

Are you applying as a delegate of a group/organization? Yes
No

If yes, which?

Has your organization formally endorsed Viva Palestina USA? Yes
No

Your organization's website:

Please contact your organization to ask for formal endorsement and notify us for their inclusion on the website.

Are you or is your organization currently involved in Palestinian issues? Yes
No

If yes, which?

Detail your participation:

Are you organizing and/or facilitating fundraising efforts in your community/region prior to departure? Yes
No

If yes, please describe and if no, are you interested in doing so?

Are you on our e-mail listserv? Yes
No

Where did you hear about this Convoy and/or Viva Palestina?

Background

Career/profession or, if pursuing a degree, area of study?

Current Employer:

Job Title:

Supervisor Name:

Supervisor Title:

Length of Employment:

Employer Address (line 1):

Employer Address (line 2):

Employer City:

Employer State:

Employer Phone:

Previous Employer:

Job Title:

Supervisor Name:

Supervisor Title:

Length of Employment:

Employer Address (line 1):

Employer Address (line 2):

Employer City:

Employer State:

Employer Phone:

Previous Employer:

Job Title:

Supervisor Name:

Supervisor Title:

Length of Employment:

Employer Address (line 1):

Employer Address (line 2):

Employer City:

Employer State:

Employer Phone:

References

Please list three, including:

a professional reference
a reference from previous humanitarian work with which you have been involved
a reference who has known you for 7 years or more

Full Name:

Company:

Address:

Phone:

Email:

Describe the relationship:

Full Name:

Company:

Address:

Phone:

Email:

Describe the relationship:

Full Name:

Company:

Address:

Phone:

Email:

Describe the relationship:

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VIVA PALESTINA INTERNATIONAL CONVOY REGISTRATION FORM