About the Internet Society 

Board of Trustees

Annual Disclosure Form

For Trustees, Institutional Officers and Senior Staff

It is mandatory that ISOC has a disclosure on file at least once each year for each Trustee, Officer and Senior Staff Member. Should there occur a change in status during the year, an amended disclosure form should be filed with ISOC.

Please fill in and print the following form and return by mail to:

Internet Society
1775 Wiehle Avenue
Suite 102
Reston, VA
20190-5108 U.S.A.

1. Is there any business relationship with ISOC between yourself or a member of your family that may represent a conflict of interest? Yes
No

If Yes, please list or elaborate such relationships and the details of annual or potential financial benefit as you can best estimate them.

2. Did you or a member of your family receive, during the past 12 months, any gifts or loans from any source from which ISOC buys good or services or otherwise has significant business dealings? Yes
No

If Yes, please list such loans or gifts, their source, and their approximate value.

3. Please identify your main employer and any consulting contracts or board seats you may have with ISOC business partners, members or sponsors.

4. Please identify any business relations you may have with other ISOC board members and the nature of those.

I certify that the foregoing information is true and complete to the best of my knowledge.

Name         

Date            

Signature    Add real signature here after printing