Membership Application

Thank you for your interest in an appointment to the FCC’s Disability Advisory Committee.

All applicants are urged to carefully read information about this membership solicitation and application instructions available in Word or PDF format. Note: Your request for membership will not be complete until submission of this form, submission of your resume, and any other supporting documents requesting.

Are you filing this request as an individual or organization? *

Organization (use this section if you are applying as the representative of an organizational applicant.)

Individual (use this section if you are applying in your individual capacity and are not a representative of an organizational applicant.)

For organizational applicants only

(Use this section if you are applying as the representative of an organizational applicant.)

Name of corporation, nonprofit, or other entity:

Organizational applicant’s primary representative:

Name:

Title:

Address 1:

Address 2:

City:

State/US Territory:

Zip:

Email address:

Phone number:

Example: 555-555-5555

Organizational applicant’s alternate representative:

Name:

Title:

Address 1:

Address 2:

City:

State/US Territory:

Zip:

Email address:

Phone number:

Example: 555-555-5555

Primary business of organizational applicant. (Check all that apply):

Disability consumer organization

Government entity

Industry (broadcast, wireless, wireline, etc.)

Trade association

Other

If other, please specify:

Nomination of representative(s):

The Commission’s ethics counsel requires that the above applicant(s) be officially nominated by your organization from a person with authority. This nomination will affirm that the nominee(s) are authorized to represent your organization at the DAC. You may be a person of authority in your organization, but it may be wise to have the nomination submitted by a second person with authority in your organization. A person with authority is someone with the authority to appoint representatives on behalf of the organization.

Please enter the email address and title of a person with authority to nominate the applicant(s) . They will receive instructions on how to complete the nomination.

Email of Person with Authority to nominate primary representative:

Title of Person with Authority:

Email of Person with Authority to nominate alternate representative:

Title of Person with Authority:

For individual applicants only

(Use this section if you are applying in your individual capacity and are not a representative of an organizational applicant.)

Name of Individual Applicant:

Address 1:

Address 2:

City:

State/US Territory:

Zip:

Email address:

Phone number:

Example: 555-555-5555

Place of Employment:

Are you a federally registered lobbyist? Check one:

Yes

NOTE: Those serving in an individual capacity and not as a representative of an organizational applicant may not be federally registered lobbyists and must also file confidential employee financial disclosure forms prior to beginning their service and annually thereafter.

For all applicants

(All applicants please complete this section.)

Are you willing to commit to a two-year term of service and attend three one-day plenary Committee meetings (to be conducted in-person or, if appropriate, by teleconference) in Washington, DC per calendar year? *

Yes

Are you willing to participate on a minimum of one working group or subcommittee as needed? *

Yes

Do you understand that the Commission does not provide compensation or honoraria for serving on the committee? *

Yes

Do you understand that the Commission does not generally reimburse travel expenses? *

Yes

Have you served previously on the Disability Advisory Committee or another FCC advisory committee? *

Yes

If so, please specify the FCC Advisory Committee name

Are you, or do you work for an entity that is, a party to an FCC contract or subcontract or providing services for the benefit of the FCC under contract or subcontract? *

Yes

Please submit a narrative statement detailing the areas of telecommunications and video programming accessibility in which you or your organization have an interest, as well as your knowledge of and expertise in these areas and on other issues to be addressed by the Committee. *

This narrative is limited to 3500 characters. You have 3500 characters remaining.

Applications will be received until 11:59 EST, August 13, 2020.

As noted in the public notice in Word or PDF, announcing this solicitation, applications are subject to the renewal of the Committee’s charter and all Committee members are subject to an ethics review prior to service.

Any questions, please contact Debra Patkin, Designated Federal Officer (DFO) of the Committee, Phone/Videophone for American Sign Language users: 202-870-5226; Email: Debra.Patkin@fcc.gov or Will Schell, Deputy DFO of the Committee, Phone: 202-418-0767 (voice or relay); Email: Will.Schell@fcc.gov.

In addition to the information provided in the online application, please complete your application as follows:

If you are applying in your individual capacity, please upload a copy of your resume on the next page.

If you are an organizational applicant, please upload a copy of both the primary and alternate representative’s resume on the next page.