IMPORTANT: (1) Please use the <Edit Contents> menu option at the top of this page when updating this page/form; and (2) You must be logged in to this site with a valid Username/Password in order to add/change SOI information.
1) Your Name:
Personal Profile Picture/Image (Optional):
|2) Stakeholder Group:|
4) ICANN Affiliation (if not covered by item 2 or 3):
5) Please identify your current employer(s):
Canadian International Pharmacy Association (CIPA)
6) Please identify your current position(s):
7) Please identify the type(s) of work performed:
CIPA is a Canadian association of licensed pharmacies that provide mail order prescription services for individuals who cannot attend a pharmacy in person.
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 minimis stock ownership you may have with any company that to your knowledge has a financial relationship or contract with 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"):|
Canadian International Pharmacy Association
|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):
14) Page last revised (updates automatically):
SOI Template v7 (5 May 2016)