EXPRESSION OF INTEREST FORM
This meeting is open to all the WSIS Stakeholders that are actively working on Information Society issues. In
order to participate in this event, as an individual or as an organization all participants are required to be
involved in activities and projects concerning the Information Society.
Participants who were duly accredited and attended onsite the 2013 WSIS Forum or WSIS+10 High-level Event
in 2014 do normally not have to complete this questionnaire, unless their data or the status of the organization
they represent has changed.
In case when credentials are easily accessible on the web (showing activities of the person and entity in the last
twelve months), direct web links to these credentials can be provided instead of completing the whole
questionnaire – The ITU reserves the right to request further documents if it deems necessary.
The e-questionnaire should be returned to wsis-accreditation@itu.int
Your first name and last name:
Name and website/blog address of the organization:
Official and verifiable e-mail of your organization:
Date of creation of the organization:
Direct links to credentials if available (to send via email):
Full name(s) & role of the Governing body/main persons of the entity (or direct web link):
If you do not have direct web links supporting your credentials, then kindly complete the parts below and
provide the requested documentation:
A: Please tick whatever applies to you:
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I am from a Governmental organization
Please provide your official business email address and several documents showing your link to the organization you
represent.
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I am from a University/Academia
Please provide a copy of your student card or letter of reference from the University.
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I am an official representative of an NGO in consultative status with ECOSOC.
ECOSOC status must still be valid in 2015.
☐
I am a representative of an NGO, civil society or business entity that was accredited to an ITU WSIS event
between 2010-2013.
Please specify which year, and please explain briefly the reason for not being able to participate in 2014:
-2-
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I am from an NGO, civil society or business entity that has neither consultative status with ECOSOC
nor accreditation to WSIS, but my entity is involved in Information Society issues.
Please specify to what other meetings in relation to information society issues you participated on behalf of your entity
in the past two years and why you would like to participate in the WSIS Forum 2015:
B: What are the main goal and objectives of your entity and what are the main involvements of your entity
in the Information Society?
C: Thank you for providing your entity’s latest annual activity report and/or any useful information to
support your accreditation.
A copy of the constitution and/by-laws of the entity, as well as further information might be requested if
the WSIS Accreditation team feel necessary.
I confirm that I have filled out this form in person and that the above is true and correct:
First & last name:
Date
Signature/entity stamp: