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5) If you currently hold elected, appointed, or selected positions within At-Large, please choose all that apply:

For each position above, please enter the term expiration date (e.g., ECM: 23 June 2014):

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

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11) 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:

12) Do you believe you are participating in the At-Large advisory 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"):

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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?

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