Domain Name Registration Form
 

*

1.

YOUR E-MAILBOX
 

 

*

2.

REGISTRATION TYPE
 

New
Modify
Delete

 

*

3.

FULLY-QUALIFIED DOMAIN NAME
 

 

*

4.

NAME OF ENTITY REPRESENTED BY DOMAIN NAME
 

 
 

5.

ORGANIZATION INFORMATION

*

 5a.

Organization Name

*

 5b.

Street Address

*

 5c.

City

*

 5d.

State

*

 5e.

ZIP Code

 
 

6.

ADMINISTRATIVE CONTACT OF ORGANIZATION

*

 6a.

Last Name

 

 6b.

First Name

*

 6c.

Organization Name

*

 6d.

Street Address

*

 6e.

City

*

 6f.

State

*

 6g.

ZIP Code

*

 6h.

Voice Phone

*

 6i.

Electronic Mailbox

 
 

7.

TECHNICAL AND ZONE CONTACT

*

 7a.

Last Name

 

 7b.

First Name

*

 7c.

Organization Name

*

 7d.

Street Address

*

 7e.

City

*

 7f.

State

*

 7g.

ZIP Code

*

 7h.

Voice Phone

*

 7i.

Electronic Mailbox

 
 

8.

SERVERS

*

 8a.

Server1 Hostname

*

 8b.

Server1 IP Address

*

 8c.

Server2 Hostname

*

 8d.

Server2 IP Address

 

 8e.

Server3 Hostname

 

 8f.

Server3 IP Address

 

 8g.

Server4 Hostname

 

 8h.

Server4 IP Address

 

 8i.

Server5 Hostname

 

 8j.

Server5 IP Address