MEMBERSHIP APPLICATION
ICANN GNSO Non-Commercial Users Constituency (NCUC)


To: 	NCUC Secretariat
	c/o The Convergence Center
	Syracuse University School of Information Studies
	307 Hinds Hall 
	Syracuse, NY 13244 USA
	Mueller@syr.edu 
Please provide the following information and send it to the address above, preferably in electronic form by email. For details and questions, please refer to the NCUC charter at http://www.ncdnhc.org/current_charter.htm  first.

A) Organisation Details
Name of the Organization: 

Name of the Director:

Domain Name of the Organization: 

Mailing Address of the Organization: 

Email address of the organization:


B) Representatives

We designate the following person as our official representative in NCUC:
Name: 

Telephone Number:

E-mail address: 

We designate the following person as our alternate representative in NCUC:
Name: 

Telephone Number:

E-mail address: 


C) Type of membership

 ___	Small Organization (under 1000 members or under 200 employees / dues: US$ 50 for two years)

 ___	Large Organization (1000 or more members or 200 or more employees / dues: US$100 for two years)
 
 ___	Request for membership fee waiver. As requested, we attach our budget details and explanation
	Membership dues must arrive to enable membership rights unless the Executive Committee issues a waiver.