Membership Application

All applicants are urged to carefully read information about this membership solicitation and application instructions available in Microsoft Word or PDF format. Note: In addition to providing the information in this online application, you must upload a copy of your resume on the next page.

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 and title:

Address 1:

Address 2:

City:

State/US Territory:

Zip:

Email address:

Phone number:

Example: 555-555-5555

Organizational applicant’s alternate representative:

Name and 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:

Please submit a narrative statement detailing the organizational applicant’s previous involvement concerning issues relevant to the Committee’s work and the applicant’s ability and willingness to contribute substantively to the Committee’s deliberations.

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

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

Are you a registered lobbyist? Check one:

Yes

NOTE: Those serving in an individual capacity and not as a representative of an organizational applicant may not be 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 in Washington, DC per calendar year? *

Yes

Are you willing to participate on a minimum of one working group or subcommittee as needed? This time commitment may be substantial depending upon the workload of the working group or subcommittee. *

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

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

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

Applications will be received until 11:59 EST, September 21, 2018.

As noted in the public notice in Word or PDF, announcing this solicitation, applications are subject to the renewal of the Committee’s charter, expected to occur on December 30, 2018 and all Committee members are subject to an ethics review prior to service.

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