At-Large Statement of Interest (SOI) Form
1) Please enter your Name: |
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2) Picture/Image: | |
3) Are you participating in the At-Large advisory process (including email and real-time discussions) as a representative of: | |
a) ALAC (if so, detail the region and term): | |
b) A Regional At-Large Organization (RALO) (if so, please detail the region, position and term): |
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c) An ICANN-accredited At-Large Structure (if so, which one): | |
d) Any ICANN Committee, Constituency or Stakeholder Group (if so, which one(s))? | |
e) Any other company or organization, whether commercial or nonprofit (if so, please detail the organization and your position): |
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4) Please identify your current employer(s): | |
5) Please identify your current position(s): | |
6) Please identify the type(s) of work performed: | |
7) Please identify your declared country of primary residence: |
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8) Please list any financial relationship beyond de minimus stock ownership you may have with any company that to your knowledge has a financial relationship or contract with ICANN: | |
9) Please identify any other relevant arrangements, interests, or benefits as requested in the following two questions: | |
a) Do you, your employer, and/or sponsor have any type of material or financial interest in the At-Large advisory process and its outcomes? | |
If the answer is “Yes,” please describe the interest: | |
b) Are there any arrangements/agreements between you and any other group, constituency or person(s) regarding your participation as a work team member? | |
If the answer is “Yes,” please describe the arrangements/agreements and the name of the group, constituency, or person(s): | |
10) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable): |
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11) Additional information (optional): | |
12) Page last revised: |
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At-Large SOI Template v3 (Feb 2014)