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NAME:

COUNTRY OF RESIDENCE:

OCCUPATION:

EMAIL ADDRESS:

OTHER CONTACT DETAILS:   (OPTIONAL)

I confirm that:

1.   I am not a member of a certified At-Large Structure (ALS)
2.   I am subscribed to the APRALO emailing list
3.   I am a permanent resident of a country within the APRALO Region
4.   If I hold a leadership position in another Supporting Organization (SO) or Advisory Committee (AC), I am aware that I am not eligible for a leadership position in APRALO
5.   I am aware that I do not automatically qualify for any funding for travel or other expenses from ICANN or APRALO
6.   I am aware that upon ceasing to meet any of the above criteria, my unaffiliated membership will be automatically terminated

YES    /  NO

STATEMENT OF INTEREST:

Current or prior experience in representing the interests of Internet consumers or end-users:

Potential interest areas within APRALO, AT-LARGE or ICANN: