Nomination Form

Thank you for your interest in serving on the FCC’s Consumer Advisory Committee (CAC) from 2022-2024. For more information about the Consumer Advisory Committee, please see its webpage: https://www.fcc.gov/consumer-advisory-committee.

IMPORTANT: The Commission issued a Public Notice on July 1, 2022, describing the nomination process, including necessary qualifications and service requirements for Committee appointees. You must review the Public Notice before completing this online form.

Nominations are due by 11:59 p.m. EST, Monday, August 1, 2022. Your nomination will not be complete until this form and all supporting documents are submitted as instructed.

The Commission is seeking nominations from: consumers who wish to serve on their own behalf; nonprofit organizations; corporations; trade associations; government agencies; and other entities from both the public and private sectors.

Are you submitting this nomination on behalf of an individual or on behalf of an organization?

Individual nomination: nomination submitted by an individual consumer seeking appointment to serve on an individual capacity.

Organizational nomination: nomination submitted by a company, organization, or other entity seeking appointment of representative(s) to serve on its behalf.

Organizational Nomination

Name of company, organization, or other entity submitting nomination

Type of entity

Non-profit Organization (including, but not limited to, consumer and disability advocacy groups, but excluding trade associations and entities that provide communications services)

Company/service provider (including for-profit corporations, partnerships, and other for-profit entities, as well as non-profit or other types of entities that provide communications services)

Trade Association (entity that represents, advocates on behalf of, or consists of members that are, companies/service providers)

Government agency or other public sector entity (excluding entities that provide communications services)

Other: please describe

Enter other…

Name of ultimate parent company[ies] (if applicable)

Primary line of business or industry sector represented (please select no more than two)

Broadcaster (TV or radio)

Cable or other multi-channel video programming service

Wireless telecommunications

Wireline telecommunications

Internet access service

Other communications-related goods or services

Other…

Enter other…

Type of Agency

Federal

State

Local

Tribal

If other, please specify

Other

Is the agency a regulator of communications service providers?

Yes

Has a representative of the entity (or an affiliated entity) served on an FCC Advisory Committee in the past?

Yes

Please identify committee(s)

Dates of service

Summarize the benefit of having this organization represented on the Consumer Advisory Committee

Proposed appointee to serve as the entity’s representative on the Committee

Name and Contact Information

Name

Title

Organizational unit

Address 1

Address 2

City

State/US Territory

Zip

Email Address

Phone Number

Resume

The proposed representative’s resume must be submitted as an electronic file in machine-readable PDF or Microsoft Word (.doc or .docx) format. The electronic file name should include the name of the entity, the word “resume,” and the last name of the proposed representative, using should use the following naming convention:

Example: entityname_Resume_lastname_of proposed representative.pdf

The file may be uploaded using the widget on the final page of this form or may be transmitted as an attachment to an email to the Committee’s Designated Federal Official, Scott Marshall, scott.marshall@fcc.gov.

Satement of Qualifications

Please describe the proposed representative’s qualifications for service on to the FCC Consumer Advisory Committee, including any specific knowledge or expertise that is relevant to the Committee.

Qualifications

Does the organizational entity seek appointment of an alternate representative to serve on the Committee on its behalf when the proposed primary representative named above is absent or unable to participate?

Yes

Alternate Representative

Name

Title

Organizational unit

Address 1

Address 2

City

State/US Territory

Zip

Email Address

Phone Number

Resume

The proposed alternate representative’s resume must be submitted as an electronic file in machine-readable PDF or Microsoft Word (.doc or .docx) format. The electronic file name should include the name of the entity, the word “resume,” and the last name of the proposed representative, using should use the following naming convention:

Example: entityname_Resume_lastname_of proposed representative.pdf

Satement of Qualifications

Please describe the proposed alternate representative’s qualifications for service on to the FCC Consumer Advisory Committee, including any specific knowledge or expertise that is relevant to the Committee.

Qualifications

Please enter the name, title, and contact information of the officer or other official submitting the certification letter.

Name and Contact Information of Certifying Official

Name

Title

Organizational unit

Address 1

Address 2

City

State/US Territory

Zip

Email Address

Phone Number

For individual applicants only

Individual Nomination

Name of Individual Applicant

Address 1

Address 2

City

State/US Territory

Zip

Email Address

Phone Number

Are you a federally registered lobbyist?

Yes

As noted in the Public Notice announcing this solicitation, all members are subject to an ethics review prior to service. If submitting as an individual/SGE and not as a representative of a company, organization, or other entity you are disqualified from serving on the Committee if you are a federal registered lobbyist. SGE members must file confidential employee financial disclosure forms prior to beginning their service and annually thereafter.

Have you served on an FCC Advisory Committee in the past?

Yes

Please identify committee(s)

Dates of service

Entity represented, if any

Resume

All nominees must submit a resume. The resume should be transmitted as an electronic file in machine-readable PDF or Microsoft Word (.doc or .docx) format, with a file name that includes the nominee’s last name and the word “resume,” using the following naming convention:

Example: lastname_Resume.pdf

The file may be uploaded using the widget on the final page of this form or may be transmitted as an attachment to an email to the Committee’s Designated Federal Official, Joshua Mendelsohn, CAC@fcc.gov.

Statement of Qualifications

Please describe your qualifications and reasons for seeking appointment to the FCC Consumer Advisory Committee, including any specific knowledge or expertise that is relevant to the Committee.

Qualifications

Confirmation that you would fulfill responsibilities if appointed to serve on the Committee

If the Commission appoints you to serve on the Committee, do you—

Commit to serve on the Committee for a two-year term?

Yes

Commit to attend and participate in three or more Committee meetings per year, either by teleconference or in person in Washington, DC?

Yes

Commit to participate in at least one working group or subcommittee (which may require dedicating a substantial amount of time, depending upon the workload of the working group or subcommittee)?

Yes

Understand that the Commission does not reimburse travel expenses and does not provide payments or honoraria for service on the Committee?

Yes

Understand that you will be required to submit personal information regarding your financial interests and other information required for appointment as a Special Government Employee (SGE), to be maintained on a strictly confidential basis, and that you will have an initial and continuing obligation to disclose any interests in, or connections to, persons or entities that are, or will be, regulated by or have interests in activities regulated by the Commission?

Yes

Thank you.