Application for "At-Large Structure" (ALS) Accreditation

Organization Contact Information

* a. Organization Official Name

a1. Organization Name in English (if available)

a2. Organization Name in Non-English Language (if available)

a3. Organization Name Acronym (if available)

b. Organization Wiki

c. Organization's official website URL

* d. Organization email address

* e. Organization phone number (include country/city codes)

* f. Organization mailing address (location and postal address, if different)

* g. Organization Country

h. Organization City

i. Upload Organization LogoChoose File

j. Primary and Secondary Contact for Organization

If accredited, the primary contact will be assumed to be that person who will cast any votes required, with the secondary person being the alternate – though your Organization may at any time change its voting and alternate representatives.

Primary contact

* Primary contact Name

* Primary contact Email

* Primary contact Telephone

If primary contact has additional contact information, please provide it below

Secondary contact

* Secondary contact Name

* Secondary contact Email

* Secondary contact Telephone

If secondary contact has additional contact information, please provide it below

Other contact

Additional contact information (name, email, telephone, etc.)

Structure and Governance

You are applying for your organization to become an At-Large Structure belonging to a specific Geographic Region (RALO).

* a. Are members of your organization residents of this specific region you seek to represent?YesNo

* b. Are the officers of your organization residents of this specific region?YesNo

Please explain the answer above in sufficient detail so that a person not familiar with your Organization would be able to understand the reasons for your answer, and reference the URLs where any statutes or operating principles or other supporting information related to this question can be found:

* c. Is your organization formally incorporated or organized under a national legal jurisdiction?YesNo

IF YES: Please describe what legal recognition it has and indicate the place of legal incorporation or registration

* d. Describe your Organization's structure (e.g. governing and decision-making bodies and processes):

* e. In what language/s does your Organization conduct its business?

About Your Members

* a. Do you have individual members with the ability to vote in or otherwise control the management of the organization?YesNo

IF NO: Describe what role individuals have in the management and work of the organization.

* b. Do you have organizations as all or part of your membership?YesNo

IF YES: Describe whether they are profit-making, non-profit-making, a mixture of both, and/or what proportion of the total membership each type of private sector organization is. Please also describe what the nature of the organizational members is: For example, are they all of a similar type or interested in a similar activity or policy area?

* c. Do you have governmental bodies, or quasi-governmental bodies, as members of your organization?YesNo

IF YES: Please describe their nature and role in the decision-making and work of your organization, and the proportion of the total membership made up of these types of organization.

* d. Describe the general membership – are they predominately of one (or more) professional background or interest group? (e.g. journalists, online rights activists, consumer organizations, individual consumers, etc.)

* e. Describe how your Organization keeps its constituents/membership informed about, and enables them to participate in, decisions regarding issues of interest:

* f. Approximately how many members of each type of membership class (if you have more than one) do you have?

* g. Explain the eligibility requirements (if any) for your Organization's constituents/membership:

Funding

* a. What is the primary source, or sources, of funding for your Organization? (if unfunded/entirely voluntary simply indicate “N/A”):

* b. Is your organization mainly self-supporting and would not be dependent on ICANN funding for the day-to-day operations of the organization?YesNo

* c. Do you receive any funding from government agencies or for-profit entities? If so, please describe below and describe their involvement in the activities of the organization (if they so participate):

Communication

* a. Does your Organization commit to supporting its individual constituents'/membership's informed participation in ICANN?YesNo

* b. Does your Organization post on the Internet publicly-accessible, current information about your Organization’s goals, structure, description of constituent group(s)/membership, working mechanisms, leadership, and contact(s)?YesNo

If this information currently is available, provide URLs

* c. Provide information on your Organization's leadership (leaders' names, positions, emails):

* d. Are the leaders of your organization, as individuals, involved in other similar organizations or entities?YesNo

If yes, please say which ones:

Signature

Include the name, and title, if applicable, of the individual who is authorized by your Organization to sign this application and commit your Organization to comply with ALS criteria.

* Signature

* Name

* Title

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