National Lawyers International Committee
Venezuela Electoral Observation Mission

approximate dates October 2 to October 9, 2012

Application Deadline: May 15, 2012

The estimated cost for this delegation is $600 to $800. Airfare will be paid for by Venezuelan authorities.

Contact Information

NAME (as appears on passport):

Name you prefer to go by, if different than passport:

PHONE (Work):

(Home):
(Cell):

EMAIL:
ADDRESS:

TOWN, STATE, ZIP:

DATE OF BIRTH: BIRTHPLACE:

PASSPORT NUMBER: EXP. DATE:

IN CASE OF EMERGENCY, PLEASE NOTIFY:

NAME: RELATIONSHIP:

ADDRESS:

PHONE NUMBERS:
Questions (take as much space as you need):

Are you a lawyer, law student, or legal worker? What kind of work do you do?:
If a law student, school and year:
Are you active in the National Lawyers Guild?:

If so, in what capacity?:

Are you active in any other organizations? Please describe:
Have you ever been to Venezuela before? If so, how often have you been and why did you go?
Have you ever participated in a brigade, delegation, or electoral observation mission before? If so, where, when, and what did you do there?
How familiar are you with Venezuela’s history, the history of US intervention in Venezuela and theAmericas, and Venezuela’s current political and economic situation? Give a brief description of what you know.
Why do you want to participate in the NLG election delegation to Venezuela? What do you hope to gain from this delegation?

What are you most excited to contribute to this delegation? Are you willing to contribute to a delegation report? Write articles? Speak publicly?
Do you have any concerns about the delegation? If so, what concerns do you have?

Are you willing to participate in a report for the NLG ?

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Are you willing to write and speak to your local media and local activists about the delegation?

There will be approximately four slots for this delegation and we expect many applications. Why should we choose you to participate?

III. Please answer the following questions:
1) Do you speak Spanish? If so, at what level? We expect to have at least one interpreter, but Spanish is an additional asset.
___None ___Beginner ___Intermediate Conversational ___Fluent ___ Interpreter
2) Do you have any particular physical or mental health needs we should know about?
3) Do you take prescription or non-prescription medication?
4) Do you have any allergies to medication or food?
5) Do you have other special needs or dietary restrictions (e.g., vegetarian, vegan)?

6) Are you willing to share a hotel room with another delegate?

7) Would you be willing/able to come to Venezuela a day or two before 10/2?

8) How did you first hear about this delegation?

I hereby declare that I have answered all of these questions honestly and to the best of my knowledge.
(Failure to answer honestly may result in your being excluded or expelled from the delegation.)

Signature______Date______

Submit this application via email to:

Email questions or call: Susan Scott, , 916-849-3695

WAIVER OF LIABILITY AND ASSUMPTION OF RISK

I, ______, voluntarily join this delegation sponsored by the National Lawyers Guild. I am participating in this delegation because I want to participate as an election observer in Venezuela. I want to better understand the situation in Venezuela and to support human rights and democracy for the people of Venezuela. I recognize and assume the risks of travel to and from and within Venezuela.
On behalf of myself, my family, heirs, representatives, executors, administrators and all other persons making any claim by reason of relationship to me, I hereby release the National Lawyers Guild and any of their affiliates, subdivisions, officers, directors, employees, advisors, agents, and representatives from any claims, damages, costs including attorneys' fees, or other liabilities resulting from personal injury, property damage, or other losses of any kind in any way connected with participation in this delegation.
I have carefully reviewed this form in its entirety and by signing below agree to its terms with full understanding of its meaning and effect. Intending to be legally bound, I am signing this Waiver of Liability and Assumption of Risk in consideration of my participation in this delegation.
Signature: ______Date: ______