At-Large Statement of Interest (SOI) Form
1) Please enter your Name: | <p>Tijani BEN JEMAA</p> |
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2) Picture/image (optional-see separate instructions): | |
3) Please select your RALO (or None): | AFRALO |
4) Please enter the name of your ALS (or None): | Fédération Méditerranéenne des Associations d'Internet (FMAI) |
5) If you currently hold elected, appointed, or selected positions within At-Large, please choose all that apply: | Executive Committee Member (ECM) |
For each position above, please enter the term expiration date (e.g., ECM: 23 June 2014): | ECM: October 2012 RALO leadership: November 2013 ALAC Member: AGM 2014 |
6) ICANN Affiliation (if not covered by item 3 or 4): | |
7) Please identify your current employer(s): | Retired |
8) Please identify your current position(s): | Executive Director of the FMAI (volunteer) |
9) Please identify the type(s) of work performed: | All executive work of the federation |
10) Please identify your declared country of primary residence: | Tunisia |
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: | None |
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? | Yes |
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"): | FMAI (my ALS) |
13) Please identify any other relevant arrangements, interests, or benefits as requested in the following two questions: | |
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? | No |
If the answer is “Yes,” please describe the interest: | |
b) Are there any arrangements/agreements between you and any other group, constituency or person(s) regarding your participation as a work team member? | No |
If the answer is “Yes,” please describe the arrangements/agreements and the name of the group, constituency, or person(s): | |
14) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable): | JAS, At-Large Improvement Task Force, RoP, Metrics, New gTLD, ICANN Academy, FBSC, Finance Ad Hoc Community Groups |
15) Additional information (optional): | |
16) Page last revised: | 09-Aug-2012 |
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At-Large SOI Template v1 (June 2012)