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1) Your Name:

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name	NAME
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content	text

Farell FOLLY

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).

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name	IMAGE

2) Stakeholder Group:

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name	SG

Africa2point0

1Registries

2Registrars

3Commercial

4Non-Commercial

5Not Applicable

3) Constituency:

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name	CONSTITUENCY

Not for Profit Foundation

1Business (BC)

2Intellectual Property (IPC)

3Internet Service Providers (ISPC)

4Non-Commercial Users (NCUC)

5Not-for-Profit Operational Concerns (NPOC)

6Not Applicable

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

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name	AFFIL
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content	text

None

5) Please identify your current employer(s):

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name	EMPLOYER
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content	text

Africa 2.0 Foundation
Building 16, Ground Floor
Woodlands Office Park
Woodmead
JohannesburgGautengRepublic of South Africa

www.africa2point0.org

6) Please identify your current position(s):

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name	POSITION
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Benin Chapter Head, Technology Champion

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

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name	WORK
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Identify ICT needs and issues in Africa and design a plan to address them efficiently. Then submit this plan to investors, international organizations, governments, donators etc.

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

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name	COUNTRY
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BENIN

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:

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

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name	REP

No (not paid to represented)

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"):

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name	REPEXPLAIN
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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?

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name	INTEREST
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Yes

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

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name	INTERESTEXPLAIN
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Participate in annual ICANN meetings and actively work to contribute in ICANN goals achievments.

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

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name	ARRANGE
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Yes

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

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name	ARRANGEEXPLAIN
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content	text

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

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name	TEAMS
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13) Additional Information (optional):

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name	INFORMATION
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14) Page last revised:

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format	dd-MMM-yyyy
name	REVISED

today

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