Application From

Organization Information

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* 1. Organization Name:

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* 2. Contact Person (Name and Position):

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* 3. Address:

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code

Country *

Email Address *

Phone Number

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* 4. Contact Email Address:

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* 5. Website or social media page (if applicable):

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* 6. Is your organization community-based or community-led? Please describe:

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* 7. Organization's Mission and Objectives:

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* 8. Brief Description of Organization's Experience in Harm Reduction and Advocacy:

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* 9. Are you applying as an initiative group using a fiscal agent?

Yes

No

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* 10. If yes, provide the name and details of the fiscal agent:

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* 11. Memorandum of Cooperation or Agreement (if applying through a fiscal agent)

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* 12. Is your organization a member of any of the following networks? Please check all that apply:

Correlation-European Harm Reduction Network

Eurasian Harm Reduction Association

Drug Policy Network South East Europe

European Network of People Who Use Drugs