ICANN 2017 Nominating Committee Leadership Positions Candidacy Application Request [Items with an asterisk (*) are required] 1) Identification and Contact Information: First or Given * Surname or Family * Contact Email Address: * Re-type Email Address: * Alternate E-mail Address: Re-type Alternate E-mail Address: Gender - Select -MaleFemalePrefer not to disclose Country of Citizenship: * 2) Position(s) for which you wish to apply: (Note: Please review the specific criteria for each of the Leadership Positions before submitting this request form. Indicate below the preference you wish the Nominating Committee (NomCom) to use in evaluating your candidacy for the available position openings). Position Preference Selection: Select the preference - 1st, 2nd, 3rd or 4th only once - or "N/A" for any position that you do not wish to be considered a candidate. Positions: Positions * 1st2nd3rd4thN/A Board Board - 1st Board - 2nd Board - 3rd Board - 4th Board - N/A GNSO GNSO - 1st GNSO - 2nd GNSO - 3rd GNSO - 4th GNSO - N/A ccNSO ccNSO - 1st ccNSO - 2nd ccNSO - 3rd ccNSO - 4th ccNSO - N/A ALAC* ALAC* - 1st ALAC* - 2nd ALAC* - 3rd ALAC* - 4th ALAC* - N/A *ALAC Leadership Positions in 2017 are for citizens of countries from Africa, Asia/Australia/Pacific Islands and Latin America/Caribbean Islands regions (see ICANN's Geographic Regions for descriptions). If you are not from one of these regions, please do not apply for an ALAC Leadership Position this year, but please return to check for vacancies during the 2018 NomCom selection process 3) Consent and Authorization: How did you hear about us? * - Select -ICANN WebsiteICANN NewsletterICANN MeetingICANN Mailing ListConferenceFacebookTwitterOther Social MediaFriendNominating Committee MemberOther Other * Under the NomCom's procedures, your candidacy will be treated as confidential unless you give the NomCom your permission to disclose it or unless the NomCom is consulting your references or conducting third-party reference checks from selected sources on a confidential basis. Third party checks may also be required as part of the candidate assessment process conducted by an external consultant and the due diligence process necessary before the NomCom can accept candidates for leadership positions in ICANN. You authorize all pages of your application, and all information contained therein, to be transmitted across jurisdictional borders and to any and all countries around the globe to the extent required for the purposes of the NomCom activities as it relates to your candidacy. This authorization relates to all pieces of the application process and not simply this application request form. You also authorize the NomCom to consult with your references and provide them with a copy of your candidate profile and application(s), to investigate other information publicly available about you, and to conduct additional confidential third-party reference checks. You also authorize the NomCom to pass your candidate profile, application(s), and references to an external consultant that may be required as part of the assessment and due diligence processes. You will not be entitled to review or access any of the information received, obtained, generated, or considered by the NomCom regarding any Candidate or Selected Nominee, or any of the NomCom's discussions or deliberations regarding any Candidate or Selected Nominees. Candidates and Selected Nominees have no right to challenge or seek review of the NomCom's selections. The NomCom will not accept unsolicited comments about a candidate from any third party. Once selections are made, the NomCom will make the identities of only the Selected Nominees public. Although the NomCom will take reasonable steps to ensure that its confidentiality procedures are followed, Candidates and Selected Nominees shall have no claims against ICANN, the NomCom or affiliated persons in the event information is disclosed despite our adherence to these procedures. Please indicate Yes that you understand the above statement and agree to become a candidate under the conditions described above: Consent Yes NEXT STEPS: The 2017 NomCom application process is being conducted within a RESTRICTED ICANN wiki space. Once you successfully submit this candidacy request form, NomCom Staff will respond to you at your Email address provided above to begin the formal application process. You should expect to receive that email communication within 5 business days. If you are not contacted within that time-frame or have any questions about this process, please write to: email@example.com For more information about the NomCom, see: https://www.icann.org/nomcom2017 CAPTCHAThis question is for testing whether you are a human visitor and to prevent automated spam submissions. Generate a new captcha What code is in the image? * Enter the characters shown in the image.