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| 1 | Date of last revision (updates automatically). |
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| 2 | Your name: |
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| 3 | Current employer(s): |
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| 4 | Current position(s): |
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| 5 | Stakeholder group, constituency and/or advisory committee: |
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| 6 | Your primary country of residence: |
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| 7 | Your primary time zone +/- UTC. Exclude any seasonal adjustments. (e.g., Los Angeles is UTC-8): Find your time zone at https://www.timeanddate.com/time/map. |
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| 8 | 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: |
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| 9 | Do you believe you are participating in this process as a representative of any individual or entity, whether paid or unpaid? If the answer is “Yes,” please provide the name of the individual or entity you represent. (If professional ethical obligations prevent you from disclosing this information, please enter "Private"). |
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| 10 | Are you, or a company you work for:
If you answered yes, please explain. |
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| 11 | What role are you interested in taking on in the RSP Program Working Group? Active participants can expect to join a call (60-90 minutes) on a weekly basis, discuss topics on a mailing list, and review documents, potentially up to two hours per week. Observers will keep abreast of the conversation by following the mailing list. There are no expectations regarding time or attendance. |
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| 12 | Briefly describe the reason for your interest in joining this group and include any expertise you would bring to discussions regarding registry service providers in the ICANN ecosystem. |
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