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Please use the <Edit Contents> menu option (directly above) to complete this form. Note that most of the fields in the right column are REQUIRED ; therefore, you will not be able to SAVE the page until they are completed.

Column

Panel

bgColor	white
titleColor	maroon
titleBGColor	lightcyan
title	STAFF USE ONLY

 Application
Status  

 Assessment 
 Due-Date 

 Assessment
Status  

Text Data

name	STAT1
type	line

Report Info

	data:RETURN > shift + 22d
format	dd-MMM-yyyy
	data:RETURN > shift + 22d

Text Data

name	STAT2
type	line

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	###

Table Data

name	TRAVELERS
initialRows	1

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

Return:

Date Data

name	RETURN
format	dd-MMM-yyyy

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

5a) Event/Conference Website Link:

Text Data

name	LINK

6) Primary Event/Conference Location:

Text Data

name	LOCATION

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

9) Purpose and Goals:

Text Data

name	PURPOSE

10) Proposed Outcomes:

Text Data

name	OUTCOMES

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

Yes A

No B

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

List Data

name	AUTH

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

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

=============================================

Panel

bgColor	lightyellow
titleColor	maroon
titleBGColor	lightcyan
title	Program Administration: STAFF USE ONLY

Table Data

name	REQUIREMENTS
initialRows	1

Program Requirement	Date Satisfied	Initials	Notes
RQMT BLOCK Structure Leader Confirmation A Stakeholder Engagement VP Confirmation B Speakers Bureau C Communications Department D Meetings Team E Constituency Travel F	SATISFIED dd-MMM-yyyy BLOCK	50px INITIALS BLOCK JDL A RH B	NOTES1 BLOCK

Panel

bgColor	lightyellow
titleColor	maroon
titleBGColor	lightcyan
title	Confirmation Section: STAFF USE ONLY

Table Data

name	CONFIRMATIONS
initialRows	1

Program Administrator	Confirmed?	Date	Rationale
STAFF BLOCK Janice Douma Lange A Rob Hoggarth B	CONFIRM BLOCK Yes A No B	CONFIRMDATE dd-MMM-yyyy BLOCK	NOTES2 BLOCK

CROPP Application Template v5 (Sep 2013)

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Old Version 19

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Trip Proposal Section

Trip Assessment Section