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Nomination Form
The Regional Consultation of the Nansen Initiative in South Asia
Bangladesh, 3-5 April 2015
The organizers will cover the cost of International air travel (round-trip, most direct economy class) for one Head of
Delegation and 3 Officials from each participating country in the Regional Consultation.
Invitations have been sent to the Ministries of Foreign Affairs in the respective countries and we intend to bring together
four representatives/policy-level officials from your esteemed country inter alia from the Ministry of Foreign Affairs and the
lead Ministries dealing with disaster management and climate change adaptation.
The Regional Consultation will be held at the City Inn Ltd, Khulna, Bangladesh and all funded participants will be
accommodated there.
Delegates nominated for funding by your esteemed Government should contact Mr Shahreen Munir (DhakaCCDM@iom.int)
with this nomination form filled out by 5 March 2015.
1. The (institution’s name)________________________________________________ herewith nominates
Mr. / Ms.___________________________Tel: ____________________ Email: _________________________
Mr. / Ms.___________________________Tel: ____________________ Email: _________________________
Mr. / Ms.___________________________Tel: ____________________ Email: _________________________
Mr. / Ms.___________________________Tel: ____________________ Email: _________________________
2. Arrival date Dhaka (ddmmyy) _______________________________
3. Departure date Dhaka (ddmmyy) _____________________________
4. Authorizing Person’s Name:___________________________________________________________
Designation/Position:____________________________________________________________
Country: _______________________________________________________________________
Address: _______________________________________________________________________
Tel: ____________________Fax: __________________Email: ___________________________