Artists at Risk Connection (ARC) - Intake Form
Thank you for contacting PEN America’s Artists at Risk Connection (ARC). Please note that ARC does not provide direct assistance, but acts as a critical connector between artists and the organizations who have direct support to help persecuted artists, including emergency funding, legal, and relocation assistance, among many other services.

Given our team’s limited capacity, we are able to assist artists who have been threatened as a direct result of their creative work.

We look forward to reading your inquiry and will be in touch soon if we believe we can offer support.
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Instructions
Please fill out this form so that we may evaluate your circumstances and determine how we can best assist you. Fill out as many fields as you can.

If there is information you do not have, skip the field. For required fields which do not apply to you, indicate "n/a". Responses to this form are encrypted. Your information will be treated as highly confidential.
Artist Information
Full Name *
Date of Birth *
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Gender *
E-mail *
Phone Number *
Referral Information
Full Name
Employer and Title
E-mail
Professional Information
What is your field of artistic practice? (Painter, filmmaker, playwright, musician, etc.) *
Please provide a brief description of your work. *
Please provide links to your work or exhibitions online. *
Details of Attack, Threat, Persecution or Censorship
Date of arrest, attack or threat *
Place of arrest, attack or threat *
If you were detained, please fill out the following section:
Length of time detained
Place of detention
Forces who arrested/detained you, or who you think were responsible, and why you think this
If arrested, the authority that issued the arrest warrant or made the decision
If released from detention, please explain how
If you suffered from any form of persecution, please describe:
Detailed description of any acts of persecution *
If you suffered from any form of censorship, please describe:
Detailed description of any acts of censorship
Additional information
Describe what you believe is the motivation of your attackers and why you believe this *
Describe what you did after the attack or threat, e.g. any police, legal or humanitarian assistance sought. What was the result of this? *
Please detail any additional reasons why you have received threats, e.g. gender, orientation, religious or ethnic identity, political affiliations
Current Situation
Describe your situation today. For example, are you able to return to your country of origin? What kinds of travel and/or residency restrictions have been applied to you? If you return to your country of origin will you or members of your family face detention or danger? *
Are you in touch with any other governments or organizations to help you seek refuge? If so, please list them below along with any additional comments. We will be able to work on your case more efficiently if we know which other groups are involved.
What type of assistance are you seeking? *
Do you have a secure way to receive funds?  *
If so, please describe (for instance, wire transfer, Paypal, an intermediary, etc) 
Have you already received assistance or have you already contacted other organizations for assistance? *
Nationality & Citizenship
Nationality *
Country or Countries of citizenship *
Do you currently have legal status in any other country? Please explain *
Do you hold a valid passport? *
If so, from what country? *
When does it expire?
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What is your present location? Please give city and country *
If not in your country of origin, when did you leave your country of origin?
If not in your country of origin, please state your immigration status in your current location, including when it will expire
What is your native language? *
Please list any additional languages you speak along with your level of fluency in each
Dependents
Please list the names of any dependents, if applicable (in most countries, legal dependents are defined as one’s spouse and children) who would accompany you in relocation. PLEASE NOTE that immigration laws in many countries may prevent you from bringing adults over the age of 21 on a dependent visa.
If you have no dependents, indicate "n/a".
Dependents *
Include name, date of birth, relationship, and passport expiry date.
Employment
Employer *
Location of Employment *
Your Position *
Dates of Employment *
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Education
Degree #1 *
Degree title, awarding institution, date awarded.
Degree #2
Degree #3
References
Please provide contact details for at least TWO individual who can speak about your work and/or artistic merit, in addition to your circumstances and threats against you.

Please include name, e-mail and your relationship for REFERENCE 1.
 *

Please include name, e-mail and your relationship for REFERENCE 2.
 *
Additional Information
How did you hear about ARC? *
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