Indigenous Leaders Conservation Fellowship

APPLICATION FORM

Note: The deadline for this application is June 15, 2014. Please e-mail this application to along with:

·  Your CV or resume, and a copy of your personal identification card

·  A nomination letter from your sponsoring community or indigenous/local organization, demonstrating that you have the support of the community in which you will be working.

·  A 2-3 page outline of your research project proposal, explaining your proposed area of work. Anything longer than 3 pages will not be considered. Please follow the project proposal guidelines (below)

·  A completed budget estimate worksheet (attached below).

Part I:

1.  Family Name:______First Name:______

2.  Gender:______

3.  Place of Birth:______Date of Birth:______

4.  Indigenous peoples group you belong to?______

5.  Nationality: ______

6.  Address: ______

7.  Telephone: ______

8.  E-mail: ______

9.  Best way to contact you:______

Part II:

10.  Region you are applying for (circle one): Mekong Basin/Indonesia Africa Amazon Basin

11.  Please circle your desired theme:

·  How traditional knowledge can contribute to biodiversity conservation and/or climate change adaptation and mitigation

·  Gender dynamics and/or women’s empowerment in Natural Resource Management and Traditional Knowledge

12.  Knowledge of Languages:

On a scale of 1-3, 1 being fluent; 2 being intermediate; and 3 being basic; please list the languages you know, and rate your skills in that language.

Language / Speaking / Writing / Reading

13.  What previous or current fellowships, scholarships or awards have you received?

14.  What is the highest level of education you have achieved? ______

15.  Do you have any connections with regional or national indigenous peoples organizations or NGOs? If yes, which ones?

16.  What type of professional development opportunities would you want to participate in if you received the fellowship?

I certify that the statements made by me in answer to the above questions are true, complete, and correct to the best of my abilities.

______

Signature Date

Estimated Budget
Professional Development Component / Description of Activity / Cost
Workshops*
Classes*
International Meetings/Conferences*
National Meetings/Conferences*
Research Project Component
Stipend* / to pay for your time, or someone else
Equipment* / such as a computer, camera, voice recorder
Travel* / to project sites where work will take place
Print Materials* / pamphlets, surveys, etc.
Match Funding
Sub Total: / If any match funding, include here
Grand Total / $16,000

* Please note that these are just suggestions- you are intended to fill this table in according to your own specific needs.

Instructions:

Please delete the suggestions above in grey, and fill in the table according to your own proposal. In the personal training component, include specific trainings or meetings you are interested in attending, if possible. In the project component, include only general costs. We do not need a complete breakdown of costs at this time. Note that the totals for each section can fall in a range, but they need to add up to $16,000 total. If you are selected for the fellowship, we will request more detailed information from you. If you have any match funding available, please include it in the third section of the table.

Indigenous Leaders Conservation Fellowship

PROPOSAL GUIDELINES

Please use these guidelines to help you formulate a 2-3 page summary of your research proposal. Anything longer than 3 pages will not be considered.

______

1.  Project title

2.  Background - where will the research take place? Why is this research important for you and the community? How are you connected to the communities in which you are planning to work (are you from there, work there, etc.)?

3.  Goals – what do you hope to achieve through this research? How will this research influence community plans or policies at the local or national level?

4.  Activities – what activities will you do?

5.  Participation – who will be participating in the research? Will you need research assistance? Will you partner with any organizations or institutions?

6.  Total estimated budget for this research – this should match the research budget in the budget worksheet

7.  Please fill in the timeline below

Activity / Mo.1 / Mo.2 / Mo.3 / Mo.4 / Mo.5 / Mo.6 / Mo.7 / Mo.8 / Mo.9
Activity1
Activity 2