At-Large Statement of Interest (SOI) Form
1) Please enter your Name: |
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2) Picture/image (optional-see separate instructions): |
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3) Please select your RALO (or None): |
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4) Please enter the name of your ALS (or None): |
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5) If you currently hold elected, appointed, or selected positions within At-Large, please choose all that apply: |
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For each position above, please enter the term expiration date (e.g., ECM: 23 June 2014): |
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6) ICANN Affiliation (if not covered by item 3 or 4): |
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7) Please identify your current employer(s): |
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8) Please identify your current position(s): |
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9) Please identify the type(s) of work performed: |
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10) Please identify your declared country of primary residence: |
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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: |
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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? |
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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"): |
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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? |
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If the answer is “Yes,” please describe the interest: |
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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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14) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable): |
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15) Additional information (optional): |
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16) Page last revised: |
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