This is a sample EoI Form for viewing only. <Edit Contents> button is disabled. If you plan to fill out an EOI, please contact staff@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 - 2019-2020: TBD
  • At-Large Board Member Candidate Reference Links & Resources - 2019-2020: TBD

If you have any questions about this process, please send an email to the At-Large staff.


  • 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, XX November 2019



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.


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

1) Name:


First or Given

Surname or Family




Picture/Image (Optional):

 Explanation

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.

  Instructions


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.



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.



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Consent and Authorization:

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