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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
7. I do not have conflicts of interest of any kind in joining APRALO

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: