[gnso-whoissurvey-dt] GNSO Statement of Interest template for WHOIS Survey Drafting Team

[Glen de Saint Géry <Glen@xxxxxxxxx>]

Dear All,

As agreed at the WHOIS Survey Drafting Team meeting, please find the GNSO 
Statement of Interest (SOI) Form.

Please provide your statement of interest  following this template and return 
it to  gnso.secretariat@xxxxxxxxxxxxxx<mailto:gnso.secretariat@xxxxxxxxxxxxxx> 
by 15 June 2011.

.
1) Please enter your Name:

2) Stakeholder Group:

3) Constituency:

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 (e.g., country to 
which you pay taxes):

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) Do you believe you are participating in the GNSO policy process as a 
representative of any individual or entity, whether paid or unpaid?

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"):

10) Please identify any other relevant arrangements, interests, or benefits as 
requested in the following two questions:

a) Do you have any type of material interest in ICANN GNSO policy development 
processes and outcomes?

If the answer is "yes," please describe the material interest in ICANN GNSO 
policy development processes and outcomes:

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):

11) Contact Email

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

13) Additional Information (optional):


Please let me know if you have any questions.
Thank you in advance for your co-operation.
Kind regards,

Glen


Glen de Saint Géry

GNSO Secretariat

gnso.secretariat@xxxxxxxxxxxxxx<mailto:gnso.secretariat@xxxxxxxxxxxxxx>

http://gnso.icann.org