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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:

 11) AccessbilityAccessibility

 22) Accountability

 33) ccTLD Policy

4)Community Networks

5)Consumer ProteProtection

ction 6)Contract Party Agreements

7)Data Protection

8) Development

9)DNS

10)E-commerce, E payments

11)Education

 1212)Engagement

13) Freedom of Expression

14) Free Use of Encryption

15) Human rights

 1616) IANA

17)ICANN I CANN Board/Bylaws/structures

18) IDN

19) Intellectual Property

20) Internet Governance

21) Internet Infrastructure

22) Internet Protocols

23) Legal/Regulatory

 2424) 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

 other