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Please use the <Edit Contents> menu option (directly above) to complete this form. Remember to <Save> the page (bottom right) after making updates. Other than the two required fields immediately below, you may complete any portion of this form, save, and return later to continue where you left off.

Trip Proposals must be completed at least six (6) weeks before the event start date.

Person Completing Form:		Date:

Application Status	Assessment Due-Date	Form ID #

Trip Proposal Section

1) Number of Travelers:
(Note: Each traveler uses one trip of the five (5) allocated to each organization/structure).

2) Traveler Contact Information and Itinerary:

Traveler	Email	From City	From Country	Depart Date	Return Date

3) Special Travel Circumstances, Arrangements,
Explanations, or Notations:
(Please identify each traveler, as applicable)

4) Event/Conference Name, Title, or Descriptor:

5) Event/Conference Dates:

Start:		End:

6) Event/Conference Website Link:

7) Primary Event/Conference Location:

Street Address:
City:		Country:

8) ICANN Geographic Region:

9) Activity Sponsors:
(Note: all event sponsors must be identified
in order to comply with ICANN travel guidelines).

10) Purpose and Goals:

11) Proposed Outcomes:

12) Additional Information (optional):

Note: To be completed by a Pilot Program Coordinator (PPC) designated by this organization/structure.

Acknowledgements

Confirmed?

Name

Date

Notes

The participants identified in this application are familiar with the Program Operations associated with this Community Regional Outreach Pilot Program (CROPP)-FY15 and agree to abide by its terms and conditions.

The ICANN Organization / Structure's leadership has authorized the submission of this Trip Proposal.

The ICANN Stakeholder Engagement Vice-President has concurred that the Purpose/Goals of this Trip Proposal are consistent with operational plans and/or strategies.