Domain Registration Form

Current Profile Based On: {{reg_domain}}/{{reg_username}} Domain Ownership Information This section is what is used to determine the owner of the domain being registered, please be complete and accurate. Domain Name: Registration Period: {{PERIOD_LIST}} First Name: Last Name: Organization Name: Street Address: Address 2: Address 3: City: State/Province: Postal Code: Country: {{OWNER_COUNTRY_LIST}} Phone Number: *optional* Fax Number: Email:

Administrative Contact Information First Name: Last Name: Organization Name: Street Address: Address 2: Address 3: City: State: 2 Letter Country Code: {{ADMIN_COUNTRY_LIST}} Postal Code: Phone Number: *optional* Fax Number: Email: Billing Information First Name: Last Name: Organization Name: Street Address: Address 2: Address 3: City: State: 2 Letter Country Code: {{BILLING_COUNTRY_LIST}} Postal Code: Phone Number: *optional* Fax Number: Email: Technical Contact Information First Name: Last Name: Organization Name: Street Address: Address 2: Address 3: City: State: 2 Letter Country Code: {{TECH_COUNTRY_LIST}} Postal Code: Phone Number: *optional* Fax Number: Email: DNS Information Primary DNS Hostname: Secondary DNS Hostname: Third DNS Hostname: Fourth DNS Hostname: Fifth DNS Hostname: Sixth DNS Hostname: