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2) Stakeholder Group: |
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3) Constituency: |
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4) ICANN Affiliation (if not covered by item 2 or 3): |
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5) Please identify your current employer(s): |
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6) Please identify your current position(s): |
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7) Please identify the type(s) of work performed: |
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8) Please identify your declared country of primary residence (e.g., country to which you pay taxes):
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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:
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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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a) Do you have any type of material interest in ICANN GNSO policy development processes and outcomes?
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If the answer is “yes,” please describe the material interest in ICANN GNSO policy development processes and outcomes:
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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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If the answer is “yes,” please describe the arrangements/agreements and the name of the group, constituency, or person(s):
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12) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable):
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13) Additional Information (optional):
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14) Page last revised:
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