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 ([email protected]) 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: ___________________________