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1) Your Name:

Text Data
name
nameNAME
width250px
NAMEcontenttext
 

Picture/Image:
(Instructions: Click in the field to the right to open up the text input window. Then click the <Insert> menu button, select <Image>, then choose (or browse) to locate an image file (e.g., JPG, PNG, BMP) from your local computer to upload. After insertion, please click on the picture and adjust the size to no larger than 200 pixels).

Text Data
nameIMAGE

 

2) Stakeholder Group:
List Data
nameSG
Registries1

 

Registrars2

 

Commercial3

 

Non-Commercial4

 

Not Applicable5

 

3) Constituency:

List Data
nameCONSTITUENCY
Business (BC)1

 

Intellectual Property (IPC)2

 

Internet Service Providers (ISPC)3

 

Non-Commercial Users (NCUC)4

 

Not-for-Profit Operational Concerns (NPOC)5

 

Not Applicable6

 

4) ICANN Affiliation (if not covered by item 2 or 3):

Text Data
nameAFFIL
width250pxnameAFFIL
contenttext
 

5) Please identify your current employer(s):

Text Data
name
nameEMPLOYER
width250px
EMPLOYERcontenttext
 

6) Please identify your current position(s):

Text Data
namePOSITION
width250pxnamePOSITION
contenttext
 

7) Please identify the type(s) of work performed:

Text Data
nameWORK
width250pxnameWORK
contenttext
 

8) Please identify your declared country of primary residence (e.g., country to which you pay taxes):

Text Data
name
nameCOUNTRY
width250px
COUNTRYcontenttext
 

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:

Text Data
nameRELATIONSHIP
width250pxnameRELATIONSHIP
contenttext
 

10) Do you believe you are participating in the GNSO policy process as a representative of any individual or entity, whether paid or unpaid?

List Data
nameREP
No

 

Yes

 

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"):
Text Data
name
nameREPEXPLAIN
width250px
REPEXPLAINcontenttext

 

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?

List Data
nameINTEREST
separatornewline
Yes

 

No

 

If the answer is “yes,” please describe the material interest in ICANN GNSO policy development processes and outcomes:

Text Data
nameINTERESTEXPLAIN
width250pxnameINTERESTEXPLAIN
contenttext
 

b) Are there any arrangements/agreements between you and any other group, constituency or person(s) regarding your participation as a work team member?

List Data
nameARRANGE
separatornewline
Yes

 

No

 

If the answer is “yes,” please describe the arrangements/agreements and the name of the group, constituency, or person(s):

Text Data
nameARRANGEEXPLAIN
width250pxnameARRANGEEXPLAIN
contenttext
 

12) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable):

Text Data
nameTEAMS
contentrichtext
 

13) Additional Information (optional):

Text Data
nameINFORMATION
contentrichtext
 

14) Page last revised:

Date Data
nameREVISED
formatdd-MMM-yyyy
today

 

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