2) 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

name	IMAGE

3) Are you participating in the At-Large advisory process (including email and real-time discussions) as a representative of:

a) ALAC (if so, detail the region and term):

Text Data

name	ALAC
width	250px
content	text

b) A Regional At-Large Organization (RALO) (if so, please detail the region, position and term):

Text Data

name	RALO
width	250px
content	text

c) An ICANN-accredited At-Large Structure (if so, which one):

Text Data

name	ALS
width	250px
content	text

d) Any ICANN Committee, Constituency or Stakeholder Group (if so, which one(s))?

Text Data

name	COMMITTEE
width	250px
content	text

e) Any other company or organization, whether commercial or nonprofit (if so, please detail the organization and your position):

Text Data

name	OTHER
width	250px
content	text

4) Please identify your current employer(s):

Text Data

name	EMPLOYER
width	250px
content	text

5) Please identify your current position(s):

Text Data

name	POSITION
width	250px
content	text

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

Text Data

name	WORKTYPE
width	250px
content	text

7) Please identify your declared country of primary residence:

Text Data

name	COUNTRY
width	250px
type	line
content	text

8) 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

name	RELATIONSHIP
width	250px
content	text

9) Please identify any other relevant arrangements, interests, or benefits as requested in the following two questions:

a) Do you, your employer, and/or sponsor have any type of material or financial interest in the At-Large advisory process and its outcomes?

List Data

name	INTEREST
separator	newline

Yes

If the answer is “Yes,” please describe the interest:

Text Data

name	INTERESTDESC
width	250px
content	text

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

name	ARRANGE
separator	newline

Yes

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

Text Data

name	ARRANGEDESC
width	250px
content	text

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

Text Data

name	TEAMS
content	richtext

11) Additional information (optional):

Text Data

name	INFORMATION
content	richtext

12) Page last revised:

Date Data

nameREVISED

format	dd-MMM-yyyy
name	REVISED

today

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