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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 as defined by APRALO Rules of Procedure Section 27.5.2.7 (see below).

YES

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:

 1) Accessbility 2) Accountability 3) ccTLD Policy 4)Community Networks 5)Consumer Protection 6)Contract Party Agreements 7)Data Protection 8)Development 9)DNS 10)E-commerce, E payments 11)Education 12)Engagement 13)Freedom of Expression 14) Free Use of Encryption 15)Human rights 16)IANA 17)ICANN Board/Bylaws/structures 18)IDN 19)Intellectual Property 20)Internet Governance 21)Internet Infrastructure 22)Internet Protocols 23)Legal/Regulatory 24)NewTLDs 25)New/Social Media 26)Net Neutrality 27)Open data/access 28)Policy Progress 29)Privacy 30)Public Interest

31)Reviews/Improvement 32)Security/Stability 33)WHOIS 34)Any other