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1) Your Name:


Text Data
nameNAME
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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


1Registries1

 



2Registrars2

 



3Commercial3

 



4Non-Commercial4

 



5Not Applicable5

 




3) Constituency:


List Data
nameCONSTITUENCY


1Business (BC)1

 



2Intellectual Property (IPC)2

 



3Internet Service Providers (ISPC)3

 



4Non-Commercial Users (NCUC)4

 



5Not-for-Profit Operational Concerns (NPOC)5

 



 6Not Applicable6




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


Text Data
nameAFFIL
 


5) Please identify your current employer(s):


Text Data
nameEMPLOYER
 


6) Please identify your current position(s):


Text Data
namePOSITION
 


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


Text Data
nameWORK
 


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


Text Data
nameCOUNTRY
 


9) Please list any financial relationship beyond de minimusminimis stock ownership you may have with any company that to your knowledge has a financial relationship or contract with ICANN:


Text Data
nameRELATIONSHIP
contentrichtext
 


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
nameREPEXPLAIN



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
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Yes

 



No
 




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


Text Data
nameINTERESTEXPLAIN
 


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
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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
 


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


Text Data
nameTEAMS
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13) Additional Information (optional):


Text Data
nameINFORMATION
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14) Page last revised:

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today

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