GICA MEMBERSHIP APPLICATION FORM

Thank you for your interest in joining GICA. You will be contacted upon review of your submission.

Before completing the following form please read the Memorandum of Understanding on GICA Membership - Common Terms.

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* 1. By checking this box I confirm that I have read and understood the language of the MOU Common Terms.

Check here

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* 2. Please indicate your organization type (if you represent a company, we encourage you to contribute by suggesting a contribution instead.

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* 3. Please provide the applying organization's ("Applicant") information:

Organization name *

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code

Country *

Website *

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* 4. To facilitate the relationship between GICA and the Applicant and, if a Memorandum of understanding on GICA Membership is signed with the Applicant, between GICA and the Member, the Applicant designates the following person to act as primary focal point used by the Secretariat for all matters related to GICA:

Name *

Designation/title *

Designation/title 2 *

Email Address *

Phone Number

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* 5. The Applicant is interested in GICA’s activities and is willing to contribute its expertise in the following types of activities:

ALL ACTIVITIES

Identifying Resources & Gaps

Sharing Good Practices

Mapping Connectivity Initiatives

Global Connectivity Outlook

From Vision to Program to Projects (V2P2P)

Monitoring & Assessing Connectivity

Other (please specify)

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* 6. The Applicant is interested in GICA’s activities and is willing to contribute its expertise in the following sectors:

ALL SECTORS

Transport

Trade

ICT

Energy

Water

Other (please specify)

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* 7. The Applicant is interested in GICA’s activities and is willing to contribute its expertise in the following regions:

Global

Africa

East Asia & Pacific

Europe & Central Asia

Latin America & Caribbean

Middle East & North Africa

South Asia

Western Europe

North America

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* 8. If your application as a GICA Member is accepted, the Applicant will be asked to sign the Member Specific- Terms of the Memorandum of Understanding on GICA Membership, reflecting the information provided in this Application. Please provide the name and title of the person which will be duly authorized to sign and will sign such Member Specific- Terms on behalf of your organization:

Name

Designation / title

Designation / title 2

Email Address

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* 9. By submitting this application you confirm that your organization is interested in becoming a GICA Member.

Yes