Membership Application

Thank you for your interest in an appointment to the FCC’s Disability Advisory Committee.

All applicants are urged to carefully read information about this membership solicitation and application instructions available in Word or PDF format. Note: Your request for membership will not be complete until submission of this form, submission of your resume, and any other supporting documents requested.

Are you filing this request as an individual or organization?

Organization (use this section if you are applying as the representative of an organizational applicant.)

Individual (use this section if you are applying in your individual capacity and are not a representative of an organizational applicant.)

For organizational applicants only

(Use this section if you are applying as the representative of an organizational applicant.)

Name of corporation, nonprofit, or other entity

Organizational applicant’s primary representative:

Name

Title

Address 1

Address 2

City

State/US Territory

Zip

Email Address

Phone Number

Organizational applicant’s alternate representative:

Name

Title

Address 1

Address 2

City

State/US Territory

Zip

Email Address

Phone Number

Primary business of organizational applicant. (Check all that apply)

Disability consumer organization

Government entity

Industry

Trade association

Other

If other, please specify

Nomination of representative(s):

The Commission’s ethics counsel requires that the above applicant(s) be officially nominated by your organization from a person with authority. This nomination will affirm that the nominee(s) are authorized to represent your organization at the DAC. You may be a person of authority in your organization, but it may be wise to have the nomination submitted by a second person with authority in your organization. A person with authority is someone with the authority to appoint representatives on behalf of the organization. Please enter the email address and title of a person with authority to nominate the applicant(s). They will receive instructions on how to complete the nomination.

Email of Person with Authority to nominate primary representative

Title of Person with Authority

Email of Person with Authority to nominate alternate representative

Title of Person with Authority

For individual applicants only

(Use this section if you are applying in your individual capacity and are not a representative of an organizational applicant.)

Name of Individual Applicant

Address 1

Address 2

City

State/US Territory

Zip

Email Address

Phone Number

Place of Employment

Are you a federally registered lobbyist?

Yes

For all applicants

(All applicants please complete this section.)

Are you willing to commit to a two-year term of service and attend three one-day plenary Committee meetings (to be conducted in-person or, if appropriate, by teleconference) in Washington, DC per calendar year?

Yes

Are you willing to participate on a minimum of one working group or subcommittee as needed?

Yes

Do you understand that the Commission does not provide compensation or honoraria for serving on the committee?

Yes

Do you understand that the Commission does not generally reimburse travel expenses?

Yes

Have you served previously on the Disability Advisory Committee or another FCC advisory committee?

Yes

If so, please specify the FCC Advisory Committee name

Are you, or do you work for an entity that is, a party to an FCC contract or subcontract or providing services for the benefit of the FCC under contract or subcontract?

Yes

Please submit a narrative statement detailing the areas of telecommunications and video programming accessibility in which you or your organization have an interest, as well as your knowledge of and expertise in these areas and on other issues to be addressed by the Committee.

Applications will be received until 11:59 EST, Monday, September 30, 2024.

As noted in the public notice (Word || PDF) announcing this solicitation, applications are subject to the renewal of the Committee’s charter and all Committee members are subject to an ethics review prior to service.

Any questions, please contact Joshua Mendelsohn, Designated Federal Officer (DFO) of the Disability Advisory Committee, at 202-559-7304 (voice or videophone) or dac@fcc.gov.

Privacy Act Statement

Authority: The Commission is authorized to pursue this collection under authorities set forth in the Federal Advisory Committee Act (FACA), 5 U.S.C. Appendix 2; 5 U.S.C. App. (“Ethics in Government Act”); and Executive Orders (E.O.) 12674 (as modified by E.O. 12731) and 14035.

Purpose: The FCC requires this information to evaluate individuals nominated for membership on the Disability Advisory Committee.

Routine Uses: The FCC may disclose information provided on this form to individuals and entities when necessary and appropriate under 5 U.S.C. § 552a(b) of the Privacy Act. For example, the name, title and organizational affiliation of Disability Advisory Committee members will be publicly available on the FCC’s website as well as on the General Service Administration’s (GSA) online FACA database. Information may also be disclosed to the Chair (or Vice Chair) of the advisory committee for purposes of determining membership on appropriate subcommittees or assignment of tasks to achieve the committee’s goals, and/or used to distribute information to the FACA committee members, their assistants, and other participants for the purposes of conducting meetings and general committee business, and/or preparing reports on the membership and work of the committee.

A complete list of the routine uses for information collected and maintained about nominees to and members of federal advisory committees can be found in the system of records notice associated with this collection, FCC/OMD-3, Federal Advisory Committee Act (FACA) Membership Files, posted at https://www.fcc.gov/managing-director/privacy-transparency/privacy-act-information.

Disclosure: This information collection is mandatory. If the requested information is not provided, the nominated representative will not be considered for membership on the Disability Advisory Committee.