Page History
...
1) Your Name: |
| |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
Personal Profile Picture/Image (Optional): |
| |||||||||
| 2) Stakeholder Group: |
| |||||||||
3) Constituency: |
| |||||||||
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): |
| |||||||||
7) Please identify the type(s) of work performed: |
| |||||||||
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: |
| |||||||||
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): |
| |||||||||
14) Page last revised: |
| |||||||||
| =========================== |
...
