Name:

E-mail: 


1.   REGISTRATION TYPE
(N)ew (M)odify (D)elete..:

2.   FULLY-QUALIFIED DOMAIN NAME:

3.   ORGANIZATION INFORMATION
3a.  Organization Name.....:
3b.  Address Line 1........:
3b.  Address Line 2........:
3c.  City..................:
3d.  State.................:
3e.  ZIP Code..............:

4.   DESCRIPTION OF ORGANIZATION/DOMAIN:

5.   Date Operational......:

6.   ADMINISTRATIVE CONTACT OF ORGANIZATION/DOMAIN
6b.  Whole Name............:
6c.  Organization Name.....:
6d.  Address Line 1........:
6d.  Address Line 2........:
6e.  City..................:
6f.  State.................:
6g.  ZIP Code..............:
6h.  Voice Phone...........:
6i.  Electronic Mailbox....:

7.   TECHNICAL AND ZONE CONTACT
7b.  Whole Name............:
7c.  Organization Name.....:
7d.  Address Line 1........:
7d.  Address Line 2........:
7e.  City..................:
7f.  State.................:
7g.  ZIP Code..............:
7h.  Voice Phone...........:
7i.  Electronic Mailbox....:
7j.  Registration Mailbox..:
7k.  Fax Number............:

8.   PRIMARY SERVER: HOSTNAME, NETADDRESS
8j.  Hostname..............:
8k.  IP Address............:

9.   SECONDARY SERVER: HOSTNAME, NETADDRESS
9a.  Hostname..............:
9b.  IP Address............:

10.  TERTIARY SERVER: HOSTNAME, NETADDRESS
10a.  Hostname..............:
10b.  IP Address............: