NEW FORM TO BECOME AN UNAFFILIATED INDIVIDUAL MEMBER OF AFRALO
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AFRICAN REGIONAL AT-‐LARGE ORGANIZATION (AFRALO) UNAFFILIATED INDIVIDUAL MEMBERSHIP
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APPLICATION FORM
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Name: ………………………………………………………………………………………………………………………………………………………………………………………………………….
Country of Residence: …………………………………………………………………………………………………………………………………………………………………….
Occupation: …………………………………………………………………………………………………………………………………………………………………………………………..
e-‐mail address: ……………………………………………………………………………………………………………………………………………………………………………………..
Phone number(s) ………………………………………………………………………………………………………………………………………………………………………………..
Other contact details (optional): ………………………………………………………………………………………………………………………………………….
How do you represent end users’ interests: …………………………………………………………………………………………………………………..
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I can confirm that (Yes / No):
1. I am not a member of a certified At-‐Large Structure (ALS)
2. I am subscribed to the AFRALO emailing list
3. I am a permanent resident of a country within AFRALO Region
4. I am active in the local Internet end users’ community
5. I accept and commit to respect the AFRALO Operating Principles/At-‐Large Advisory Committee (ALAC) Rules of Procedure/ICANN Bylaws.
Acknowledgement: I confirm that I am aware that:
• Upon ceasing to meet any of the above criteria, my unaffiliated membership will be terminated
• I have to complete the Statement of Interest (SoI) upon acceptance of my application
Please complete the SoI online form at https://community.icann.org/x/jg8QAg
• Current or prior experience in representing the interests of Internet end-‐users (if applicable): please include reference to any social media, blogs, web pages you may have or run: Potential interest areas within AFRALO, At-‐Large or ICANN (Please select from the list below):
• ICANN/PTI structure and/or Bylaws
• Internet Unique Identifiers
• Security/Stability
• Public Interest
• Accountability
• WHOIS
• gTLD Policy
• ccTLD Policy
• Consumer Protection
• Contracted Parties’ Agreements
• Data Protection
• Capacity Building
• Outreach
• Engagement
• Internationalized Domain Names and Universal Acceptance
• Intellectual Property
• Internet Governance
• Internet Infrastructure
• Legal/Regulatory
• New TLDs
• Open data/access
• Privacy
• Reviews/Improvement
Any other:…………………………………………………………………………………………………………………………….…………………………………………………….
Date:………………………………………………….
Applicant Signature:………………………………………………….
