Forum Member/Liaison Profile



Participant Status:  [ ] Member      [ ] Liaison   (check one)


Official Name:            ______________________________________________________

Short Name/Acronym:       ____________   (optional, blank if Liaison)

Host Organization:        ______________________________________________________

Constituency:             ______________________________________________________

Technical Expertise:

       Operating Systems: ______________________________________________________

       System Platforms:  ______________________________________________________

       Networks:          ______________________________________________________

       Additional:        ______________________________________________________

Forum/Liaison Contact Information:

       Regular Phone #:   ___________________________     Country Code: ______

       Emergency Phone #: ___________________________

       Facsimile #:       ___________________________

       STU III:           ___________________________

       Electronic Mail:   ______________________________________________________

       Mailing Address:   ______________________________________________________

                          ______________________________________________________

                          _________________________________________________________________________________________

                          ______________________________________________________
Principal Personnel Information: (for use only within the Forum)

       Name of Forum Representative or Liaison: ________________________________

       Regular/Emergency Phone #: _____________________________________________

       E-mail Address: ________________________________________________________


       Other team members:

       Name: ______________________________

       Regular/Emergency Phone #: _____________________________________________

       E-mail Address: ________________________________________________________


       Name: ______________________________

       Regular/Emergency Phone #: _____________________________________________

       E-mail Address: ________________________________________________________


       Name: ______________________________

       Regular/Emergency Phone #: _____________________________________________

       E-mail Address: ________________________________________________________


Remarks: