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DOMAIN NAME REGISTRATION

Please fill in the following information form. The most important information and the information that is required for you to register a domain name have big red Xs after them.

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0a. Authorization Type:
0b. Authorization Scheme:: 0c. Authorization Info:

1. Enter your comments in the space provided below:

2. Enter Domain: X

Organization Using Domain Name

3a. Organization Name	X
3b. Street Address:....	X
3c.City:......................	X
3d: State:...................	X
3e. Postal Code:........	X
3f. Country:...............	X
3g. Phone Number:....	X
3h. Fax Number:........	X
3i. Email Address:.....	X
3j. Url if applies:.......

Administrative Contact

4a. BR Handle (if Known):
4b. (I)ndividual (R)ole:.......
4c.Name (Last, First).........
4d: Organization:................
4e. Street Address:............
4f. City:.............................
4g. State:...........................
4h. Postal Code:................
4i. Country:......................
4j. Phone:.........................
4k. Fax:.............................
4l. Email:...........................

Technical Contact

5a. BR Handle (if Known):
5b. (I)ndividual (R)ole:.......
5c.Name (Last, First).........
5d: Organization:................
5e. Street Address:............
5f. City:.............................
5g. State:...........................
5h. Postal Code:................
5i. Country:......................
5j. Phone:.........................
5k. Fax:.............................
5l. Email:...........................

Billing Contact

6a. BR Handle (if Known):
6b. (I)ndividual (R)ole:.......
6c.Name (Last, First).........
6d: Organization:................
6e. Street Address:............
6f. City:.............................
6g. State:...........................
6h. Postal Code:................
6i. Country:......................
6j. Phone:.........................
6k. Fax:.............................
6l. Email:...........................

Prime Name Server

7a. Primary Server Hostname:
7b. Primary Server Netaddress.

Secondary Name Server(s)

8a. Sec Server Hostname:
8b. Sec Server Netaddress.

9a. Registration Period (1-5 yrs):

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