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NEW FILLABLE FORM TO BECOME AN UNAFFILIATED INDIVIDUAL MEMBER OF AFRALO

ENFRAR

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AFRICAN REGIONAL AT-­‐LARGE ORGANIZATION (AFRALO) UNAFFILIATED INDIVIDUAL MEMBERSHIP

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APPLICATION FORM (EN)
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Name: Aly DIOUF ………………………………………………………………………………………………………………………………………………………………………………………………………….

Country of Residence: Senegal …………………………………………………………………………………………………………………………………………………………………….

Occupation:  Entrepreneur …………………………………………………………………………………………………………………………………………………………………………………………..

e-­‐mail address:senegalsoft@gmail ……………………………………………………………………………………………………………………………………………………………………………………..com

Phone number(s): (+221) 775058495 ………………………………………………………………………………………………………………………………………………………………………………..

Other contact details (optional): ………………………………………………………………………………………………………………………………………….

How do you represent end users’ interests:Promote respect for privacy and access for all to Internet resources …………………………………………………………………………………………………………………..

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I can confirm that (Yes / No): 

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Any other:…………………………………………………………………………………………………………………………….…………………………………………………….

By submitting my personal data, I agree that my personal data will be processed in accordance with the ICANN Privacy Policy, and agree to abide by the website Terms of Service.

  •  I agree

Date:  Date:………………………………………………….

Applicant Signature: Aly DIOUF ………………………………………………….