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Warning

This is a sample EoI Form for viewing only. <Edit Contents> button is disabled. If you plan to fill out an EoI, please contact program-admin@atlarge.icann.org.

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Instructions: If you are new to this EoI Form, please click in this box to review IMPORTANT INFORMATION to assist you in completing this Form

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This EoI Form contains Profile Sections(A-C) and a separate Application Section (D) for this At-Large Board Member Selection cycle.

Please use the <Edit Contents> menu option (above) to complete all form sections and always remember to <Save> your page (see the button at the bottom right) (Note: We recommend that you NOT click the <Save Draft> button because its operation is not intuitive, you may lose your work). If you are unable to complete the entire form in one session, you may return multiple times to complete it using <Edit Contents> and <Save> when finished.

To indicate to the Program Admin Staff that you are finished working with the EoI Form, please complete the "Consent and Authorization" area at the bottom and click <Save>. As soon as realistically possible, Program Admin Staff will validate your final submission for completeness and subsequently restrict it from further editing

The right column contains data fields which are either free-form text, drop-down selection menus, or numeric. For certain text fields, clicking your mouse in the cell will bring up an Editor offering an extensive menu at the top containing formatting options including: headings, fonts, bullets, paragraph indentation, links, tables, and an insert menu offering even more capabilities (e.g., images, attachments).

As a precautionary measure, there are very few embedded links in this EoI Form to prevent being transported out and potentially losing your work. External materials that can be referenced are marked in orange bold text. If you need to consult any of these documents, be sure to <Save> your active page (see the button at the bottom right of this Form) and return to it when convenient. If you are comfortable working in multiple tabs/windows and want to visit any external source while working in this document, be sure to <Right-Click> the link using your mouse (or pointing device) to open it in another tab/window. For your convenience, all documents and materials referenced in this year's application process are contained on these pages: 

If you have any questions about this process, please send an email to the Program Admin Staff.

IMPORTANT:

  • DO NOT change the Page Title (top left) under any circumstances.
  • This EoI Form must be completed in English. Please set your browser in the English language setting in order to avoid auto-translation of the EoI Form by your browser to other languages.
  • All EoI forms will be closed to further editing effective 23:59 UTC on Friday, 18 November 2016
Note

IMPORTANT:

  • Please use the <Edit Contents> menu option (above) to complete all form sections and always remember to <Save> your page. You may resume your progress and return multiple times to complete the EoI Form using <Edit Contents> and <Save> when finished.
  • When you have finished entering ALL of the applicable information for this EoI Form and are prepared to release it to the BCEC, please complete the Consent & Authorization immediately below Section D.

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Section A: Identification, Contact Information, Resume, and Professional References

1) Name:
First or GivenSurname or Family
Text Data
nameFNAME
width200px
typeline
contenttext

 

Text Data
nameLNAME
width200px
typeline
contenttext

 

Picture/Image (Optional):

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Explanation

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In order to provide Candidates with as many options to promote their qualifications as are feasible, the BCEC is inviting each Candidate to submit a photograph in the form of an uploaded picture/image.

IMPORTANT: If you choose not to take advantage of this option, there will be no detrimental effect upon your candidacy.

To provide a picture, please read the instructions below.

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 Instructions

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Click in the field to the right to open up the text input window. Then click the <"+" Insert more content> 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) Gender:
List Data
nameGENDER
width100px
Male

 

Female

 

Other

 

3) Email Addresses:  
Primary:
Text Data
nameP-EMAIL
width250px
typeline
contenttext

 

Alternate:
Text Data
nameA-EMAIL
width250px
typeline
contenttext

 

4) Telephone/Contact Numbers:

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Instructions

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Please include all international, country, and city/area codes, e.g., +64 1111 2222. Use the "+ Add Row" to add additional rows to the table; the "x" can be used to delete rows added by mistake.

 

Table Data
nameTELEPHONE
initialRows1
TypeNumber (or ID)
CONTACTBLOCKALandline

 

BMobile

 

CSkype

 

TELNO200pxlinetextBLOCK

 

5) Country of Citizenship:
If you have multiple citizenships, please list them comma-separated.
Text Data
nameCITIZEN
width300px
contenttext

 

6) Domicile: 

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Instructions

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Domicile means the country that you treat as your permanent home, or live in and have a substantial connection with. If you reside in more than one country, please state the percent of time you reside in each country as a whole digit number without the '%' sign. Use the "+ Add Row" to add additional rows to the table; the "x" can be used to delete rows added by mistake.

 

Table Data
nameCOUNTRY
initialRows1
CountryPercent
RES-COUNTRY1150pxlinetextBLOCK 1100PCT-COUNTRY175pxBLOCK

7) If you have a personal Web page, Blog, Facebook, Twitter or YouTube Channel, you may provide links here.

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Instructions

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Click inside the text box to open the input window. Highlight one of the bullets; then, from the top menu, select Link, choose Web Link, then enter the information. You may alter the appearance in the "Link Text" field or accept the default. Click Done and the information will be inserted as automatically linkable.

 

Text Data
nameLINKS
  • Link1
  • Link2
  • Etc. 

8) Resume:

If you have a resume or curriculum vitae (C.V.), the Committee would appreciate having it uploaded it to this page (PDF preferred) and then linked within this question. Your uploaded resume should not exceed the equivalent of five (5) single-spaced typewritten pages.

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 Instructions

 

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Click inside the text box (right column) to open the input window. On the top menu, click the <"+" Insert more content> menu button; select Attachment; then use the Choose File (or Browse) option to locate the document on your computer. You may alter the link's appearance by adding a description in the "Link Text" box at the bottom of the window.


Text Data
nameRESUME
 
9) Professional References:

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Explanation

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Please provide the names of no less than three (3) and no more than four (4) people who know you in a professional capacity and are willing to provide you a written Reference for your candidacy at short notice.

As soon as possible after the deadline for submission of EoI Forms at 23:59 UTC on Friday, 18 November 2016, the BCEC and its Program Admin Staff will contact each of the people you name as a Referee directly to request their written References to be submitted by 23:59 UTC on Friday, 2 December 2016. Referees may subsequently be approached to answer questions or provide clarification.

The BCEC may send a copy of your EoI Form to each of the people you name as a Referee.

Before submitting your Referees' names and contact information via this EoI Form, Candidates must explain to their Referees the purpose of the At-Large Board Member Selection process and obtain their Referees’ consent that they are willing to be contacted to send written References and answer questions or provide clarifications at short notice. 

The BCEC recommends that Candidates choose their Referees carefully so the BCEC has a broad view of a Candidate’s experiences and abilities. Individuals from the following groups may not be submitted as Referees: 

  • Current BCEC Members
  • Current ALAC Members 
  • Current ICANN Staff

The BCEC will not consult as a Referee anyone who is also a Candidate under consideration for the At-Large Board Member. The BCEC encourages Candidates to identify this issue with any prospective sources to avoid an unusable Reference. Because of our confidentiality commitment, the BCEC will be unable to advise Candidates about another person's presence in the Candidate pool. This will become evident when the list of all Candidates names is made publicly available; however at that stage it will be too late to submit a substitute Reference.

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Instructions

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In the column to the right, please provide your Referee's name, e-mail address, telephone number, professional position, and a brief description of your relationship with them. 

Use the "Add Row" to add additional rows to the table; the "x" can be used to delete rows added by mistake.

 

Table Data
nameREFERENCES
initialRows3
Name

Email

TelephoneRelationshipYears Known
R-NAME200pxlinetextBLOCK

 

R-EMAIL200pxlinetextBLOCK

 

R-TEL120pxlinetextBLOCK

 

R-RELATION150pxlinetextBLOCK

 

YRSKNOWN75pxINLINE

Section B: Qualifications & Professional Background

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Purpose of This Section

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The purpose of Section B is to help the Committee understand the skills and experience you would bring to ICANN, how you would help ICANN achieve its mission, and how you meet the criteria for the leadership position the BCEC will fill. Please refer to the At-Large Board Member Candidate Requirements - 2017 page for a description of the criteria. The BCEC needs to understand why you are the right person for the position to which you are applying. Please be bold in telling the Committee about yourself and your ideas.

 

1) Please describe any current and past volunteer positions, roles, and accomplishments. The Committee is particularly interested in Board or similar directorship experience. Please include the name and web page of such organizations, if applicable.
Text Data
nameVOLUNTEER

 

2a) Have you held or do you currently hold a Board or executive management position in any organization? 
List Data
nameEXEC
Yes

 

No

 

2b) If "Yes," please state the nature and size of the organization(s) in which you currently hold or have held a Board or executive management position.
Text Data
nameEXECDESC

 

3a) Do you have experience working with non-profit organizations?
List Data
nameNON-PROFIT
Yes

 

No

 

3b) If "Yes," please state the nature and size of any non-profit organization(s) including any Board positions or executive committees upon which you currently serve or have served.
Text Data
nameN-PDESC

 

4) Briefly describe any experience you have had working with groups in various locations and time zones around the globe.
Text Data
nameTIME-ZONE

 

5) Being able to read and to express yourself publicly in English is mandatory for leadership positions at ICANN.  Do you meet this criterion?
List Data
nameENGLISH
Yes

 

No

 

6) Which other languages do you speak and at what level of fluency?

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Instructions

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Use the "+ Add Row" to add additional rows to the table; the "x" can be used to delete rows added by mistake.

 

Table Data
nameLANGUAGES
initialRows1
LanguageLevel of FluencyNumber of Years
LANG100pxlinetextBLOCK

 

FLUENCYBLOCKAElementary proficiencyLevel 1

 

BLimited working proficiencyLevel 2

 

CProfessional working proficiencyLevel 3

 

DFull professional proficiencyLevel 4

 

ENative or bilingual proficiencyLevel 5

 

L-YEARS75pxINLINE

Section C: Internet & ICANN Involvement

1) Describe your current and past involvement in, contributions to, and leadership roles in activities and organizations involved in the development and operation of the Internet, its naming and addressing infrastructure, and/or its security and stability. 

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Explanation

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Please describe any involvement with the operation of ccTLD, gTLD registries or registrars, IP address registries, or relevant DNS technical or policy development process, including Internet technical protocols and standards. Your answer should include details of any involvement with ICANN's policy development processes, including its creation and evolution; Supporting Organizations; Councils; and/or Advisory Committees.

 

Text Data
nameROLES

 

2) Conflicts of Interest

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Instructions

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Please indicate clearly if you have any areas of actual or potential conflicts with ICANN. Please refer to the ICANN Conflicts of Interest Policy which specifically addresses conflicts for ICANN Directors, Officers and key employees. If you have had any relationship with an ICANN accredited registry or registrar (other than registering a domain name) or any organization that has been in dispute with ICANN, please describe that relationship here. Conflicts of interest are not necessarily disqualifying, since we anticipate that many experienced people may have such relationships. The At-Large Community selected Board Member should be independent from ICANN Stakeholders whose financial situation is significantly affected by ICANN decisions.


Text Data
nameP-COI

 

3) Please explain any positions you hold as Director, major shareholder, or employee of a Generic Top Level Domain (gTLD) Registrar or Registry, Country Code Top Level Domain (ccTLD) Registry or a Regional Internet Registry (RIR).
Text Data
nameRELATIONSHIPS
 

Section D: Application for At-Large Board Member Position

1) Please state your opinion about what would be your unique expertise or perspective and what added value you might contribute to the ICANN Board:
Text Data
nameB-OPINION

 

2) Please describe how and why you meet the criteria for this position:

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Instructions

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See At-Large Board Member Candidate Requirements - 2017 document for eligibility criteria and other selection factors. Describe how your work and other experience helps you meet the criteria for the position you are applying for. You may wish to describe how your previous experience is relevant to your candidacy.

 

Text Data
nameB-CRITERIA

 

3) Please state what you would contribute in the At-Large selected ICANN Board Member Position to the At-Large Community
Text Data
nameB-CONTRIBUTION

 

4) Please describe specifically how and why you will be able to advance, at the ICANN Board, the interests of the At-Large Community and the broader global community of Internet end-users.
Text Data
nameB-INTERESTS

 

5) Time Commitment:

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Explanation

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The basic responsibilities of an ICANN Director require a minimum commitment of time which when averaged out over the year is roughly equivalent to 20-24 hours each week. This includes participation in three ICANN meetings/year, two Board retreats/year and work on Board Committees. The time spent in these basic responsibilities is typically clustered around Board meetings and monthly teleconferences, but there is a constant flow of information requiring attention on a near daily basis.

Directors are expected to attend three ICANN meetings per year and depending on the location and including travel time and preparation this could be a commitment of about ten (10) days per meeting. In addition the board occasionally holds shorter face-to-face meetings such as retreats.

Directors spend additional time in connection with their work on Board Committees, a commitment that varies in relation to the number of Committees on which they serve, the scope of the Committee's responsibilities, and their role as Chair or Member of the Committee.

Are you able to commit this amount of time for this position?

List Data
nameB-COMMIT
Yes

 

No

 

6) Please describe your understanding of changes to ICANN's Bylaws, organizational structure, and accountability mechanisms that have been put in place as part of the transition of the stewardship of IANA functions. Please also describe any personal involvement you have had in these changes.
Text Data
nameB-BYLAWS

 

 =======================================================

Consent and Authorization:

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Please click here to complete the Consent and Authorization section of this EoI Form

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Dear Candidate:

The statements below seek your consent and authorization for actions that may be taken by the At-Large Board Candidate Evaluation Committee (BCEC) in its consideration of your Expression of Interest (EoI).

You acknowledge and/or authorize that:

  • The BCEC will make publicly available a list of the names and domiciles of all Candidates, who have completed and submitted their EoI Forms by the deadline.
  • Before the final slate of Candidates has been announced, your completed EoI Form will be treated as confidential, but may be shared on a confidential basis with your Referees or with selected independent sources should the BCEC consider third party checks advisable.
  • After the final slate of Candidates has been announced:
    • The BCEC will make publicly available the EoI Forms, without disclosing any personal/private information, of the final slate of Candidates, including any additional Candidates who are successfully petitioned by the Regional At-Large Organizations (RALOs) to be added to the final slate.
    • The EoI Forms of Candidates who have not been selected in the final slate will continue to be treated as confidential.
  • Your Referees are required to submit their References by 23:59 UTC on Friday, 2 December 2016.
  • Your References will not be shared with any persons other than the BCEC and its Program Admin Staff.
  • The BCEC may consult with your Referees, investigate other information publicly available about you, and conduct additional independent reference checks. You will not be entitled to review or access any of the information received, obtained, generated, or considered by the BCEC regarding your EoI Form or any of the BCEC’s discussions or deliberations regarding you or any other Candidate.
  • Although the BCEC will take reasonable steps to ensure that its confidentiality procedures are followed, Candidates shall have no claims against ICANN, the BCEC, Program Admin Staff or affiliated persons in the event that information is disclosed despite our adherence to these procedures.
  • The information supplied by you herein is complete, accurate, and provided in good faith.
  • Your EoI Form will be closed to further editing effective at 23:59 UTC on Friday, 18 November 2016 and that, if your EoI Form has not been submitted or if your submitted EoI Form is found to be incomplete at that time, it will not be considered by the BCEC.

When you have finished completing all of the applicable information contained in this EoI Form (Sections A to D), please indicate your understanding of and agreement to this Consent and Authorization and that you seek to become a Candidate under the conditions described above.

Please select "Yes - Agree and Submit", complete the date field below, and click <Save> (see the button at the bottom right) to signify that:

  1. The Program Admin Staff may perform a completeness validation;
  2. This EoI Form may be closed to further editing; and
  3. BCEC members may begin reviewing it.

(Note: All forms will be closed to further editing effective 23:59 UTC on Friday, 18 November 2016).

 
I understand and agree to the above
provisions and submit my completed
EoI Form for consideration by BCEC:

EOICONSENTINLINEYes - Agree and Submit

 

No - Disagree and Don't Submit

 

Date:

dd-MMM-yyyyEOIDATEINLINE

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titleBGColorlightcyan
titleProgram Administration: STAFF USE ONLY
Profile StatusApplication StatusRegion Designation
Text Data
nameP-STATUS

 

Text Data
nameB-STATUS

 

List Data
nameREGION
AAF

 

BAP

 

CEUR

 

DLAC

 

ENA

 

Table Data
nameREQUIREMENTS
initialRows1
Program RequirementDate SatisfiedInitialsNotes
RQMTBLOCKA1) Candidate Page Created/Restricted

 

B2) Candidate Notified

 

C3) Consent and Authorization Entered

 

D4) Page Validated/Editing Restricted

 

E5) Committee Notified

 

dd-MMM-yyyySATISFIEDBLOCKINITIALS50pxBLOCKAAL

 

BTA

 

CYN

 

NOTES1400pxtextBLOCK

 

At-Large Board Candidate Application Template v1 (Oct 2016)