GNSO Statement of Interest (SOI) Form
1) Please enter your Name:
1) Your Name:
Picture/image (optional-see separate instructions):
|2) Stakeholder Group:|
| 4) |
4) ICANN Affiliation (if not covered by item 2 or 3):
5) Please identify your current employer(s):
5x5 Communications LLC
6) Please identify your current position(s):
7) Please identify the type(s) of work performed:
Public relations and policy 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:
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):
1112) 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:
SOI Template v3 (10 October 2012)