EXPRESSION OF INTEREST

Non-governmental organizations and civil society entities currently in consultative status with ECOSOC, interested to participate in the preparatory process of the World Summit on the Information Society
(Please send this form to the Executive Secretariat not later than 6 weeks before a PrepCom)

(THIS FORM SHOULD BE FILLED OUT IN ONE OF THE UN-LANGUAGES)

Name of the organization / entity

In consultative status with ECOSOC since when

Year:

Please indicate your status:

• general consultative status

• Special consultative status

• Roster

(Please tick the respective box)

Mailing Address

Country

Telephone number(s)

Fax Number(s)

E-mail

Website

http://

Information concerning the contact person:

Mr / Mrs

Surname: _______________________________________________

First Name: _______________________________________________

Position: _______________________________________________

Country: _______________________________________________

Phone : _______________________________________________

Fax : _______________________________________________

E-mail : _______________________________________________

Information on the person legally responsible

Mr / Mrs

Surname: _______________________________________________

First Name: _______________________________________________

Position: _______________________________________________

Country: _______________________________________________

Phone : _______________________________________________

Fax : _______________________________________________

E-mail : _______________________________________________

Please send the filled-out form to the following mailing address:

Executive Secretariat
World Summit on the Information Society
c/o ITU, Office V 552
Place des Nations
CH-1211 Geneva 20

or send the filled-out form by fax to the
Executive Secretariat of WSIS, ++41 22 730 63 93

E-mail for inquiries: wsis.csd@ties.itu.int