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Trip Proposal Section

1) Number of Travelers:
(Note: each traveler uses one trip of the five (5) allocated to each organization/structure).

Number Data

minValue	1
maxValue	5
name	TRIPS
format	###
required	true

Table Data

name	TRAVELERS
initialRows	1

Traveler	Email (Redacted)	Alternate	Email (Redacted)
TRAVELER BLOCK line true	gsecmntyrgnloutrchprgm:admin any BLOCK T-EMAIL BLOCK line true	ALTERNATE BLOCK line	gsecmntyrgnloutrchprgm:admin any BLOCK A-EMAIL BLOCK line

2) Application Date:

Date Data

name	APPDATE
format	dd-MMM-yyyy

today

3) Dates of Requested Travel:

Departure:

Date Data

name	DEPART
format	dd-MMM-yyyy
required	true

Return:

Date Data

name	RETURN
format	dd-MMM-yyyy
required	true

4) Travel Itinerary:

From City:

Text Data

name	FROM1
type	line

Country:

Text Data

name	FROM2
type	line

To City:

Text Data

name	TO1
type	line

Country:

Text Data

name	TO2
type	line

 Other:
 (Describe) 

Text Data

name	OTHER

5) Event/Conference Name, Title, or Descriptor:

Text Data

name	EVENT
required	true

5a) Event/Conference Website Link:

Text Data

name	LINK

6) Primary Event/Conference Location:

Text Data

name	LOCATION
required	true

7) ICANN Geographic Region:

List Data

name	REGION

Africa A

Asia B

Australasia/Pacific Islands C

Europe D

Latin America and Caribbean E

Middle East F

North America G

Russia/CIS/Eastern Europe H

8) Activity Sponsors:
(Note: all event sponsors must be identified in order to comply with ICANN travel guidelines).

Text Data

name	SPONSORS
required	true

9) Purpose and Goals:

Text Data

name	PURPOSE
required	true

10) Proposed Outcomes:

Text Data

name	OUTCOMES
required	true

11) Additional Information (optional):

Text Data

name	INFO-PROPOSAL

ACKNOWLEDGEMENTS (Required):

The participants identified in this application are familiar with the Program Operations associated with this Community Regional Outreach Pilot Program (FY14) and agree to abide by its terms and conditions.

List Data

name	T&C
required	true

Yes A

No B

 The ICANN Organization/Structure's leadership has authorized the submission of this Trip Proposal. 

List Data

name	AUTH
required	true

Yes A

No B

 The ICANN Stakeholder Engagement Vice-President has concurred that the Purpose/Goals of this Trip Proposal are consistent with operational plans and/or strategies. 

List Data

name	RVP
required	true

Yes A

No B

Trip Assessment Section

1) Describe how the original Purpose and Goals were accomplished:

Text Data

name	PURPOSE2

2) Describe how the original Outcomes were achieved:

Text Data

name	OUTCOMES2

3) Date Completed:

Date Data

name	COMPLETED
format	dd-MMM-yyyy

4) Additional information pertaining to this outreach event (optional):

Text Data

name	INFO-EVAL

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Trip Proposal Section

Trip Assessment Section