Submission form

STORY SUBMISSION FORM

  1.       Story title:______________________________________________________________________
  2.       Submitted by:___________________________________________________________________
  3.       Position or job;__________________________________________________________________
  4.       Address:_______________________________________________________________________
  5.       Phone number:__________________________________________________________________
  6.       Fax number:____________________________________________________________________
  7.       Email address:__________________________________________________________________
  8.       Please provide contact details for two independent referees to validate your story
  9.       Name:_______________________ Position or job:_______________________________

______________________________________________________________________________

Phone:____________________     Email:______________________

  1.       Name:_______________________Position or job:_______________________________

Phone:____________________Email:______________________

9. Why do you think this story deserves an award?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Declaration

I declare that the submitted story is (tick the relevant circles);

  •    true
  •    about me
  •    about another individual or group but I have been given the agreement to document this story for this purpose. See signed consent form below
  •    the documentation of the story is my original work

Name: _____________________   Signature:  ______________         Date:_____________

Consent form

I___________________of_________________agree that my story can be documented on video, photo and audio for the purpose of submitting it to SPC RRRT for the 2013 Pacific Human Rights Awards. I understand and agree that this story can be published in future SPC RRRT publications.

Name:______________________Signature:_______________ Date:________________________



SPC’s Regional Rights Resource Team receives core funding from the Australian Government and additional project support from the Kingdom of the Netherlands, Pacific Leadership Programme (PLP), European Union (EU) and the German Development Bank (KfW).