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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 Prote

ction 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

 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