This is a sample EoI Form for viewing only. <Edit Contents> button is disabled. If you plan to fill out an EoI, please contact program-admin@atlarge.icann.org.

Instructions: If you are new to this EoI Form, please click in this box to review IMPORTANT INFORMATION to assist you in completing this Form

IMPORTANT:

  • Please use the <Edit Contents> menu option (above) to complete all form sections and always remember to <Save> your page. You may resume your progress and return multiple times to complete the EoI Form using <Edit Contents> and <Save> when finished.
  • When you have finished entering ALL of the applicable information for this EoI Form and are prepared to release it to the BCEC, please complete the Consent & Authorization immediately below Section D.

Section A: Identification, Contact Information, Resume, and Professional References

1) Name:
First or GivenSurname or Family

Picture/Image (Optional):

Explanation

 Instructions

 

 

2) Gender:

3) Email Addresses:  
Primary:
Alternate:

4) Telephone/Contact Numbers:

Instructions

 

TypeNumber (or ID)

5) Country of Citizenship:
If you have multiple citizenships, please list them comma-separated.

6) Domicile: 

Instructions

 

CountryPercent

7) If you have a personal Web page, Blog, Facebook, Twitter or YouTube Channel, you may provide links here.

Instructions

 

  • Link1
  • Link2
  • Etc. 

8) Resume:

If you have a resume or curriculum vitae (C.V.), the Committee would appreciate having it uploaded it to this page (PDF preferred) and then linked within this question. Your uploaded resume should not exceed the equivalent of five (5) single-spaced typewritten pages.

 Instructions

 


 
9) Professional References:

Explanation

Instructions

 

Name

Email

TelephoneRelationshipYears Known

Section B: Qualifications & Professional Background

Purpose of This Section

 

1) Please describe any current and past volunteer positions, roles, and accomplishments. The Committee is particularly interested in Board or similar directorship experience. Please include the name and web page of such organizations, if applicable.

 

2a) Have you held or do you currently hold a Board or executive management position in any organization? 

2b) If "Yes," please state the nature and size of the organization(s) in which you currently hold or have held a Board or executive management position.

 

3a) Do you have experience working with non-profit organizations?

3b) If "Yes," please state the nature and size of any non-profit organization(s) including any Board positions or executive committees upon which you currently serve or have served.

 

4) Briefly describe any experience you have had working with groups in various locations and time zones around the globe.

 

5) Being able to read and to express yourself publicly in English is mandatory for leadership positions at ICANN.  Do you meet this criterion?

6) Which other languages do you speak and at what level of fluency?

Instructions

 

LanguageLevel of FluencyNumber of Years

Section C: Internet & ICANN Involvement

1) Describe your current and past involvement in, contributions to, and leadership roles in activities and organizations involved in the development and operation of the Internet, its naming and addressing infrastructure, and/or its security and stability. 

Explanation

 

 

2) Conflicts of Interest

Instructions


 

3) Please explain any positions you hold as Director, major shareholder, or employee of a Generic Top Level Domain (gTLD) Registrar or Registry, Country Code Top Level Domain (ccTLD) Registry or a Regional Internet Registry (RIR). 

Section D: Application for At-Large Board Member Position

1) Please state your opinion about what would be your unique expertise or perspective and what added value you might contribute to the ICANN Board:

 

2) Please describe how and why you meet the criteria for this position:

Instructions

 

 

3) Please state what you would contribute in the At-Large selected ICANN Board Member Position to the At-Large Community

 

4) Please describe specifically how and why you will be able to advance, at the ICANN Board, the interests of the At-Large Community and the broader global community of Internet end-users.

 

5) Time Commitment:

Explanation

Are you able to commit this amount of time for this position?

6) Please describe your understanding of changes to ICANN's Bylaws, organizational structure, and accountability mechanisms that have been put in place as part of the transition of the stewardship of IANA functions. Please also describe any personal involvement you have had in these changes.

 

 =======================================================

Consent and Authorization:

Please click here to complete the Consent and Authorization section of this EoI Form

At-Large Board Candidate Application Template v1 (Oct 2016)

  • No labels

For comments, suggestions, or technical support, please email: program-admin@atlarge.icann.org
© 2016 Internet Corporation For Assigned Names and Numbers