1) Your Name:
|2) Stakeholder Group:||Non-Commercial|
|Non-Commercial Users (NCUC)|
4) ICANN Affiliation (if not covered by item 2 or 3):
5) Please identify your current employer(s):
6) Please identify your current position(s):
Senior Consultant, Internet Infrastructure and Governance
7) Please identify the type(s) of work performed:
Internet infrastructure, policy and governance consulting
8) Please identify your declared country of primary residence (e.g., country to which you pay taxes):
9) 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:
My current employer has completed consulting contracts for ICANN.
10) Do you believe you are participating in the GNSO policy process as a representative of any individual or entity, whether paid or unpaid?
|If the answer is “Yes,” please provide the name of the represented individual or entity. (If professional ethical obligations prevent you from disclosing this information, please enter "Private"):|
|11) Please identify any other relevant arrangements, interests, or benefits as requested in the following two questions:|
a) Do you have any type of material interest in ICANN GNSO policy development processes and outcomes?
If the answer is “yes,” please describe the material interest in ICANN GNSO policy development processes and outcomes:
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):
12) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable):
13) Additional Information (optional):
I understand that as a member of the GNSO Council I am conflicted out of taking part in any consulting or other paid work for ICANN. My current employer, Interconnect Communications, understands this and accepts that I will not take part in any proposals or work for ICANN, or any discussions about such work.
14) Page last revised:
SOI Template v5 (6 Feb 2014)