CSO Hub Membership Form Please fill out the information below to submit your membership application to the East Africa Civil Society Organizations Hub. OK Question Title * 1. Name of your organization. English National/Local Language OK Question Title * 2. Organization Acronym OK Question Title * 3. Location of the headquarters of your organization (city, country). OK Question Title * 4. Please list any other office locations. OK Question Title * 5. Contact phone number (with country code) OK Question Title * 6. Primary email address for the organization/contact person. OK Question Title * 7. Name of the contact person. OK Question Title * 8. Organization Type NGO/Charity Religious Entity Academic Institution Private Business Government Entity Other (please specify) OK Question Title * 9. Year of Establishment and Registration Establishment Registration OK Question Title * 10. Country of Registration Primary Others OK Question Title * 11. Operational Languages Primary Others OK Question Title * 12. Mission Statement OK Question Title * 13. Please include a short summary of your organizations work on P/CVE or relevant topics (i.e. list of specific projects or participation in relevant trainings). OK Question Title * 14. Please include a short summary of your current (ongoing) P/CVE programs or research, if any. OK Question Title * 15. Please indicate which regions or areas your programming/research is focused on. OK Question Title * 16. Please indicate your primary sources of funding (which donors but not amounts). OK Question Title * 17. Please list any affiliations you have with NGO/civil society networks. Please note this will not preclude you from membership in the CSO Hub. OK Question Title * 18. Is there any other relevant information you wish to share? OK Question Title * 19. The CSO Hub collaborates with the IGAD Center of Excellence for Preventing and Countering Violent Extremism (ICEPCVE) in Djibouti. Do we have your permission to share information about your organization with ICEPCVE? Yes No I would like to speak to someone about this. OK Question Title * 20. ICEPCVE facilitates a virtual platform for information sharing, networking, and P/CVE research. Are you interested in receiving more information on this platform? Please note, the email address provided will be shared with ICEPCVE for this purpose. Yes No I would like to speak with someone about this. OK DONE