Membership Application

Thank you for your interest in serving on the FCC’s Consumer Advisory Committee (CAC) from 2024-2026. 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 August 5, 2024, 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. EDT, Friday, September 6, 2024. Your nomination will not be complete until this form and all supporting documents are submitted as instructed.

For clarifying questions, please contact Keyla Hernandez-Ulloa, Consumer Advisory Committee (CAC) Designated Federal Officer (DFO) and David M. Pérez, CAC Deputy DFO, 202-418-0664, CAC@fcc.gov.

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.

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.

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, Keyla Hernandez-Ulloa, 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.

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—

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

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

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

Thank you.

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 Consumer 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 Consumer 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 Consumer Advisory Committee.