Your details

Name(*)

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E-mail address:(*)

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Is this a nomination for a region-independent seat?(*)

Yes

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If yes, what is the name of the Member you are a Nomination Representative for?

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Nominee details

Full name of nominee:(*)

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Date of Birth:(*)

Please enter a valid date of birth. You must be at least 18 years old

Sex:(*)

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Nationality(*)

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Country of Residence(*)

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Physical address(*)

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Organisation (or affiliation)(*)

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Position(*)

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E-mail address:(*)

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Contact phone number (include country code)(*)

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Nomination information

Is this a nomination for a region-independent seat? (*)

Yes

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Sub-region nominated for(*)

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Brief Motivation of the Nominee (max 1500 characters): (*)

0/1500

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Professional Background of the Nominee (max 3000 characters): (*)

0/3000

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Please upload a copy of the Nominee’s CV:

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Please upload a current or recent photo of the Nominee:(*)

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Please upload a form of identification from the Nominee (e.g., a passport, driver’s licence etc.): (*)

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Seconder details

Notice:

Nomination Representatives do not need to fill out this section.
For Self-Nominations or Nominations by those other than Nomination Representatives, please provide details of two seconders who must be Nomination Representatives of AFRINIC Members.

Seconder 1

Name:(*)

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Organisation(*)

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Position(*)

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E-mail address(*)

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Contact phone number (include country code):(*)

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Seconder 2

Name:(*)

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Organisation(*)

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Position(*)

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E-mail address(*)

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Contact phone number (include country code)(*)

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Statement of truth

I declare that, to the best of my knowledge and belief, that the information provided in this nomination form is true.

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