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NAME:

COUNTRY OF RESIDENCE:

OCCUPATION:

EMAIL ADDRESS:

OTHER CONTACT DETAILS:   (OPTIONAL)

I confirm that: YES (L) or NO (R)

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 terminated

STATEMENT OF INTEREST: I  acknowledge that I will complete the SOI upon acceptance (please check box):

Current or prior experience in representing the interests of Internet consumers or end-users, if applicable please include reference to any social media, blogs, web pages you may have or run:

Potential interest areas within APRALO, At-Large or ICANN (Please select from the list below):

•  Accessibility
•  Accountability
•  ccTLD Policy
•  Community Networks
•  Consumer Protection
•  Contract Party Agreements
•  Data Protection
•  Development
•  DNS
•  E-commerce, E payments
•  Education
•  Engagement
•  Freedom of Expression
•  Free Use of Encryption
•  Human rights
•  IANA
•  ICANN Board/Bylaws/structures
•  Internationalized Domain Names and Universal Acceptance
•  Intellectual Property
•  Internet Governance
•  Internet Infrastructure
•  Internet Protocols
•  Legal/Regulatory
•  New TLDs
•  New/Social Media
•  Net Neutrality
•  Open data/access
•  Policy Progress
•  Privacy
•  Public Interest
•  Reviews/Improvement
•  Security/Stability
•  WHOIS
•  Any other