Please enable JavaScript in your browser to complete this form.Applicant DetailsTell us about yourselfApplicant Full Name *FirstLastEmail *Phone *Current Address *Employment Status *EmployedSelf-EmployedUnemployedYear of Birth *What is your sexual orientation? (pick only ONE) *GayLesbianBisexualHeterosexualPansexualAsexualQueerWhat is your gender identity? (pick only ONE) *Transgender Man (you were born female, but identify as male)Transgender Woman (you were born male, but identify as female)Cisgender Man (If you were born male, and still identify as male)Cisgender Woman (you were born female, and still identify as female)Gender Non-Binary (You do not identify as strictly a man or a woman)Intersex (you were born with sexual or reproductive anatomy that doesn't seem to fit the typical definitions of female or male)Fund Request DetailsTell us what you need the requested funds forApplicant Background Information (Please provide us with detailed information about you that can help us know more about you and the emergency requiring this support) *What are you requesting emergency funds for? Tick all that apply *Legal Representation - You need funds for legal representationMedical Support - You need funds for medical support including hospitalisation and drugsOtherHow much do you need? (Write an exact amount of Naira in words) *Request Justification (Please provide information on why you need this support and any justification that can help the Application Review Board understand your request) * Provide as much detailed information as you can in not more than 800 words. If you are requesting for multiple reasons (e.g. Legal and Medical Support), make sure your justification covers all.ReferencesPlease provide the contact details of two persons who can confirm who you are and your situationReference 1 - Name of Referee *Reference 1 - Email Address of Referee *Reference 1 - Phone Number of Referee *Reference 1 - What is your relationship with the referee? *Reference 2 - Name of Referee *Reference 2 - Email Address of Referee *Reference 2 - Phone Number of Referee *Reference 2 - What is your relationship with the referee? *Supporting DocumentsPlease provide documents that can support your request and provide legitimacy to your claims. For example, pictures of the event, medical bill/invoice or prescription, travel invoice. Only upload documents that are relevant to your request.Upload Supporting Documents Click or drag files to this area to upload. You can upload up to 6 files. Submit
