Canadian Resettlement Scheme-ProtectDefenders

Eligibility Screening Request Form

You can submit this application to: canada-program@protectdefenders.eu

You can find information regarding our eligibility and criteria in this section on our website.

It is possible to communicate with the Secretariat of ProtectDefenders.eu via encrypted email (PGP). If you believe encrypted e-mail is necessary and do not know how to use PGP encryption, do not hesitate to contact us for our PGP key.

You may also use https://www.protonmail.com which is a free, safe and secure service, recommended by our Digital Security team.

If you want to send us the document encrypted, but do not have the software, please look at the following websites:

General information about Digital Security: https://www.digitaldefenders.org/digitalfirstaid/

https://www.apc.org/en/irhr/digital-security-firs-aid-kit

Information on emailing encrypted: https://securityinabox.org/en/guide/gpg4usb/windows

Please answer the following questions

Filling all fields is mandatory upon relevance and availability of information. If a field does not apply to you, please indicate “Not Applicable”. If you do not have sufficient information to fill a certain field, please explain the reason.

"*" indicates required fields

1a) CONTACT DETAILS OF THE APPLICANT

Full name*

Gender*

Name of the organisation (if any)

Country of origin **

Country of residence **

Preferred contact method*

Phone number*

E-mail address **

1b) CONTACT DETAILS OF THE HUMAN RIGHTS DEFENDER (IF DIFFERENT FROM THE APPLICANT)

Full name*

Gender*

Name of the organisation (if any)

Country of origin*

preferred contact method*

Phone number*

E-mail address*

2a) FAMILY COMPOSITION AND DEPENDENTS

Please indicate name, gender and date of birth of the family members that are included in your application. Please note that applications are by default made for nuclear family members and parents, siblings, etc can only be considered on exceptional and case by case basis. If you wish to include non-nuclear family members, please provide name, gender and date of birth about them, and additionally explain the reasons you consider them your de-faco dependent. Please feel free to add rows to the table below in case of need.

FAMILY COMPOSITION*

NAME

RELATION

GENDER

DoB

LEGAL STATUS/NOTES

2b) LEGAL DOCUMENTATION AND REGISTRATION

Please explain what is your current legal status in the country that you reside (citizen, refugee, asylum seeker, migrant). Please describe what kind of legal documentation (including travel documents and visas) you have and the validity period of those documents (250-2000 words). If the status of your family members is different from yours, please indicate and explain.

LEGAL DOCUMENTATION AND REGISTRATION*

3. AREA OF WORK

Please insert a description (250 – 4000 characters) of your work as Human Rights Defender (background and area of work and what your work consists of). If you are/have been a member of an organisation, please also describe a) the organisation's mission and main focus of work, b) duration of your work with them and c) your position, roles and contribution with the organization:

AREA OF WORK*

4. SECURITY AND RISKS

Please describe (250-8000 characters) the events that has prompted your application. What security risks are you facing and why? Please include information about the type of threats, authors of the threats, frequency, date and format of the threats, and possible evidence (e.g., links, references, documents, recordings, etc). Any files containing evidence can be attached to the e-mail sent to us. Please insert a short description for each piece of evidence:

SECURITY AND RISKS*

5. CURRENT LIVING CONDITIONS

Please describe (250-2000 words) your current living conditions, including place of residence, source of income, who you live with, if there are children in the family, if the children go to school, if there are pregnant or breastfeeding women in the family, and any other specific needs (health, disability, protection) that you or your family members might have.

CURRENT LIVING CONDITIONS*

6. SIMILAR APPLICATIONS SUBMITTED

1) Did you make similar applications for resettlement/immigration with any other resettlement stream or country?

No/Yes*

Name(s) of the stream/country(s)*

Date of the application*

Latest updates on the application*

2) Have you received any grants/financial support from other organisation in the last two years? If so, specify who, amount and costs covered.

No/Yes*

From which organisation did you receive the grant?*

When did you receive the grant?*

What was the grant allocated for?*

Amount of money received for this grant*

7. REFERENCES

please provide contact details (name, organisation, phone, email, Skype account, etc.) for at least two references who are well known within the human rights community in your country or internationally and who know your human rights work and the risks and threats that you face as a result of your activities. Please note that the references should preferably not be working at the same organisation as the Applicant/Human Rights Defender. If you are able to provide organizational email addresses from your references, that would be preferable.

REFERENCE 1

R1-Name*

R1-Organisation*

R1-Contact Details*

R1-How does this person know you?*

REFERENCE 2

R2-Name*

R2-Organisation*

R2-Contact Details*

R2-How does this person know you?*

8) BUDGET

If you are selected for this program, would you need financial support to be able to benefit from this program and travel to Canada? (i.e. costs to cover evacuation from Afghanistan or living costs in a third country during the waiting period). If so, please provide a budget with a breakdown of costs and an explanation on how costs have been defined. Please note that this table is meant for us to be able to assess whether or not we would be able to provide you with this financial support to enrol in this program, in case you are assessed eligible for it. This is not an Emergency Grant request, and we cannot guarantee that you will receive this support even if you are assessed eligible.

Please indicate the currency which you will use when filling out the budget form:

Currency*

8-List-Budget*

ITEM/COMPONENT

UNIT VALUE

NUMBER OF UNITS / MONTHS

TOTAL

DESCRIPTION

9) HOW DID YOU HEAR ABOUT PROTECTDEFENDERS.EU?

9-HOW DID YOU HEAR ABOUT PROTECTDEFENDERS.EU?*

10) CONFIDENTIALITY:should any specific information about the request be kept confidential? As a general rule, ProtectDefenders.eu will not disclose individual names and contact information to any party outside of the organisation, except for those who are required to know this information for decision making purposes, and according to the manual of the program.

Name

This field is for validation purposes and should be left unchanged.

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Canadian Resettlement Scheme for Human Rights Defenders at risk

Eligibility Screening Request Form

Please answer the following questions

Canadian Resettlement Scheme for
Human Rights Defenders at risk