ACCREDITATION FORM

For non-governmental organizations and civil society entities

(not needed if the NGO is currently in consultative status with ECOSOC or a ITU Sector member)

Entities wishing to participate in PrepCom-3 of the Tunis Phase (19-30 September 2005) or the Summit (16-18 November 2005) should submit this form before 8 August 2005

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

Name of the organization / entity

Mailing Address

Country

Telephone number(s)

Fax Number(s)

E-mail

Website

http://

Legal status

Year established

Brief Summary of the purpose and the activities of your organization / entity

(10 lines max.)

Note: this Summary will be published in English in the official document for Accreditation. Please fill this out carefully. To the extent possible, please put the summary in English. If the summary is not in English, the Executive Secretariat will translate it into English.

Purpose of the organization / entity

List of members of the governing body and their countries of origin (nationality)

Total number of members and geographical distribution, if applicable

Programs and activities in areas relevant to the subject of WSIS, and indicating in which country, or countries, they are carried out

To complete your accreditation, send to the Executive Secretariat of WSIS copy of the following documents:

• Annual report(s) with financial statement(s), and a list of financial sources and contributions, including Government contributions, if applicable

• Constitution and/or by-laws of your organization / entity

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 : _______________________________________________

Review and sign this statement :

I confirm that the above information is true and complete. I understand that my organizations / entity’s application is subject to review and approval by the World Summit Preparatory Committee in line with the decisions taken at PrepCom-1.
I further understand that the rights of participation are determined by the Rules of Procedure of the Preparatory Committee and of the Summit. Accreditation for the World Summit on the Information Society does not imply financial support for my participation.

Signed: ____________________________________

Name and title: ____________________________________

Date: ____________________

Please send the filled-out form together with the copies of the documents required above 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 and the required copies of the documents by fax to the
Executive Secretariat of WSIS, ++41 22 730 63 93

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

Thank you for applying for accreditation to the World Summit on the Information Society!