| 1. Domain Name |
.................................................................................. |
| 2. Domain details |
| 2a. (N)ew (M)odify (D)elete |
.................................................................................. |
2b. Purpose/Description.
If Modify, describe
fields to be modified |
.................................................................................. |
| 3.Organization Using Domain Name |
| 3a. Organization Name |
.................................................................................. |
| 3b. Street Address |
.................................................................................. |
| 3c. City |
.................................................................................. |
| 3d. State |
.................................................................................. |
| 3e. Postal Code |
.................................................................................. |
| 3f. Country |
.................................................................................. |
| 4.Administrative Contact |
| 4a. NIC Handle (if known) |
.................................................................................. |
| 4b. Name |
.................................................................................. |
| 4c. Organization Name |
.................................................................................. |
| 4d. Street Address |
.................................................................................. |
| 4e. City |
.................................................................................. |
| 4f. State |
.................................................................................. |
| 4g. Postal Code |
.................................................................................. |
| 4h. Country |
.................................................................................. |
| 4i. Phone Number |
.................................................................................. |
| 4j. Fax Number |
.................................................................................. |
| 4k. E-Mailbox |
.................................................................................. |
| 5.Technical Contact |
| 5a. NIC Handle (if known) |
.................................................................................. |
| 5b. Name |
.................................................................................. |
| 5c. Organization Name |
.................................................................................. |
| 5d. Street Address |
.................................................................................. |
| 5e. City |
.................................................................................. |
| 5f. State |
.................................................................................. |
| 5g. Postal Cod |
.................................................................................. |
| 5h. Country |
................................................................................... |
| 5i. Phone Number |
.................................................................................. |
| 5j. Fax Number |
.................................................................................. |
| 5k. E-Mailbox |
.................................................................................. |
| 6.Billing Contact |
| 6a. NIC Handle (if known) |
.................................................................................. |
| 6b. Name |
.................................................................................. |
| 6c. Organization Name |
.................................................................................. |
| 6d. Street Address |
.................................................................................. |
| 6e. City |
.................................................................................. |
| 6f. State |
................................................................................... |
| 6g. Postal Code |
.................................................................................. |
| 6h. Country |
.................................................................................. |
| 6i. Phone Number |
.................................................................................. |
| 6j. Fax Number |
.................................................................................. |
| 6k. E-Mailbox |
.................................................................................. |
| 7.Primary Name Server |
| 7a. Primary Server Hostname |
.................................................................................. |
| 7b. Primary Server Netaddress |
.................................................................................. |
| 8.Secondary Name Server(s) |
| 8a. Secondary Server Hostname |
.................................................................................. |
| 8b. Secondary Server Netaddress |
.................................................................................. |
| 9.Payment Method |
| 9a. (B)ank transfer |
.................................................................................. |
| 9b.(E)urocard/MasterCard |
.................................................................................. |
| 9c.(V)isa |
.................................................................................. |
