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. Question Title * 1. By checking this box I confirm that I have read and understood the language of the MOU Common Terms. Check here Question Title * 2. Please indicate your organization type (if you represent a company, we encourage you to contribute by suggesting a contribution instead. Country representative (e.g. ministerial official) Multilateral development bank International organization Established association Other (please specify) Question Title * 3. Please provide the applying organization's ("Applicant") information: Organization name Address Address 2 City/Town State/Province ZIP/Postal Code Country Website Question Title * 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 Question Title * 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) Question Title * 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) Question Title * 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 Question Title * 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 Question Title * 9. By submitting this application you confirm that your organization is interested in becoming a GICA Member. Yes No Submit
