Test Company ABC (Illustrative)

1) Name of Member:

2) Online Presences (e.g., Website, Twitter, Facebook, et al.)

3) Member's Country location (e.g., headquarters or principal office), years in business, revenue threshold, and employee count threshold:

4) Regions in which Member conducts operations, maintains office locations, and has employees:

Member Contact Info

5) Names

Picture/Image (Optional):

6) Submitter's Title/Position:

7) Email Addresses:

8) Telephone/Contact Numbers:

1) Primary Classification (Select One:)

2) Primary Business Sector (Select one):

2a) If you chose "Other" above, please provide an explanation:

3) Describe your organization's primary business activity:

4) Describe the specific business activity under which you are applying to the BC and why you wish to join:

5) What type of membership are you requesting:

6) What is the main source of the organization's revenue:

7) How would you describe your organization's customers (Select all that apply):

7a) If you wish to elaborate or provide additional explanation, please do so here (optional):

8) Please list all memberships within ICANN structures, including Supporting Organizations (e.g., GNSO), Stakeholder Groups (e.g., CSG), Constituencies, and Advisory Committees. Include your organization's voting status and principal contact to that ICANN structure:

9) Please explain any relationships your organization has as owner, director, or major shareholder of a Generic Top Level Domain (gTLD) Registrar or Registry, Country Code Top Level Domain (ccTLD) Registry or a Regional Internet Registry (RIR).

10) If you are a consultant, advisor, or legal representative (attorney), please list your major clients in the space provided. If confidentiality prohibits revealing individual names, please describe the major business areas in which your clients operate.

Section C: Affirmations

1) Our organization and its Member and Alternate Representatives accept and agree to abide by the Business Constituency's Mission and Principles (see Charter).

2) Our selected Member and Alternate Representatives will only represent user or consumer perspectives within the Business Constituency.

3) Our organization is not owned, controlled by, or under common ownership with any entity that votes in the Business Constituency or another Stakeholder Group or Constituency in either house of the GNSO.

4) Our organization (a) does not represent governments in any way or in any capacity at ICANN; and (b) is not primarily a political operation whose primary purpose is to elect government officials.

5) In submitting this application form, our organization agrees to (a) pay the applicable membership fee promptly after invoicing, (b) opt-in to the mailing list, (c) appoint a Member Representative (MR), and (d) abide by the terms of the Business Constituency Charter.

6) The organization affirms that it does not derive more than 30% of its revenue from any/all of the following (collectively "Contracted Parties" to ICANN): registry operations, registrar, and domain name reseller.

7) The organization affirms that all of the information contained in this form is accurate and may be trusted as reliable for the purposes of assessing BC membership eligibility.

Section D: Supplemental Information

If there is anything else that the organization wishes to document concerning this application or renewal, please explain: