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1) Your Name: |
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Personal Profile Picture/Image (Optional): |
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| 2) Stakeholder Group: | Not Applicable |
3) Constituency: | Not Applicable |
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 minimis 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? | No |
| 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"): | NA |
| 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? |
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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): | |
13) Additional Information (optional): | |
14) Page last revised: | |
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SOI Template v5 (6 Feb 2014)
