Shadrack Mohammed Kojo Inusah SOI

1. Please enter your Name:

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3. Are you participating in the At-Large advisory process (including email and real-time discussions) as a representative of:

a) ALAC (if so, detail the region and term):

b) A Regional At-Large Organization (RALO) (if so, please detail the region, position and term):

c) An ICANN-accredited At-Large Structure (if so, which one):

d) Any ICANN Committee, Constituency or Stakeholder Group (if so, which one(s))?

e) Any other company or organization, whether commercial or nonprofit (if so, please detail the organization and your position):

4. Please identify your current employer(s):

5. Please identify your current position(s):

6. Please identify the type(s) of work performed:

7. Please identify your declared country of primary residence:

8. 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:

9. 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?

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?

If the answer is “Yes,” please describe the arrangements/agreements and the name of the group, constituency, or person(s):

10) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable):

11) Additional information (optional):

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