Sample Expression of Interest (EoI) Form - 2017 Cycle

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.

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.

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:

At-Large Board Member Candidate Requirements - 2017: https://community.icann.org/x/HAu4Aw
At-Large Board Member Candidate Reference Links & Resources - 2017: https://community.icann.org/x/Jgu4Aw

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

IMPORTANT: 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.

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

1) Name:

First or Given	Surname or Family

Picture/Image (Optional):

Explanation

Instructions

2) Gender:

3) Email Addresses:

Primary:
Alternate:

4) Telephone/Contact Numbers:

Instructions

Type	Number (or ID)

5) Country of Citizenship:
If you have multiple citizenships, please list them comma-separated.

6) Domicile:

Instructions

Country	Percent

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

Instructions

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.

Instructions

9) Professional References:

Explanation

Instructions

Name	Email	Telephone	Relationship	Years Known

Section B: Qualifications & Professional Background

Purpose of This Section

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.

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

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.

3a) Do you have experience working with non-profit organizations?

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.

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

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

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

Instructions

Language	Level of Fluency	Number of Years

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.

Explanation

2) Conflicts of Interest

Instructions

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).

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:

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

Instructions

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

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.

5) Time Commitment:

Explanation

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

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.

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

Consent and Authorization

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:

The Program Admin Staff may perform a completeness validation;
This EoI Form may be closed to further editing; and
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:		Date:

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

Content

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Sample Expression of Interest (EoI) Form - 2017 Cycle

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.

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.

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

Section B: Qualifications & Professional Background

Section C: Internet & ICANN Involvement

Section D: Application for At-Large Board Member Position

Consent and Authorization