Thursday, March 23, 2017
A PROJECT ON STRENGTHENING THE NETWORK OF INDIGENOUS PEOPLES HUMAN RIGHTS DEFENDERS FOR THE PROMOTION AND PROTECTION OF HUMAN RIGHTS OF INDIGENOUS PEOPLES IN ASIA

A PROJECT OF THE ASIA INDIGENOUS PEOPLES PACT FUNDED BY THE EUROPEAN COMMISSION

Secretariat: 108 Moo 5, Tambon Sanpranate, Amphur Sansai, Chiang Mai 50210 Thailand, email:aippmail@aippnet.org

FUND FOR INDIGENOUS PEOPLES HUMAN RIGHTS DEFENDERS AT RISK

I. INFORMATION ON BENEFICIARY AND ASSISTING ORGANIZATION
For individual beneficiary/ies (to be filled up only if request is being made for individual/s)

(Add more lines if beneficiary is more than one)


For community beneficiary (to be filled up only if request is being made for a community)

II. SITUATION

Please provide a summary of the event that has prompted your request for assistance. Please attach a factsheet of the case.

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III. ASSISTANCE

Please check the box below for the assistance needed

E. PLEASE PROVIDE AN ITEMIZED BUDGET OF HOW THE MONEY IS GOING TO BE USED:

Sample Budget

Item Description Cost in Local Currency No of Units Counterpart Amount Requested
1
2
3
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Maximum size 10MB

F. BANK ACCOUNT DETAILS

In case the request for assistance is approved, please provide the bank account details where the grant will be sent:

1. Name of Account
2. Address of Account Holder
3. Account Number
4. Name of Bank
5. Bank Address
6. SWIFT CODE


IV. CONFIDENTIALITY

Should any specific information about the request be kept confidential? AIPP does not disclose individual names and contact information to any party outside of the organization.

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Signature of Beneficiary or Authorized Person with the Assisting Organization

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