Domain Name Registration Form

REGISTRATION TYPE ...........: [New] [Delete] [Modify]

FULLY-QUALIFIED DOMAIN NAME .: 

DESCRIPTION OF DOMAIN .......: 

ORGANIZATION INFORMATION:
a. Organization Name.........: 
b. Street Address ...........: 
c. City .....................: 
d. State ....................: 
e. ZIP Code .................: 

ADMINISTRATIVE CONTACT OF ORGANIZATION:
a. Last Name ................: 
b. First Name ...............: 
c. Organization .............: 
d. Street Address ...........: 
e. City .....................: 
f. State ....................: 
g. ZIP Code .................: 
h. Voice Phone ..............: 
i. Electronic Mailbox .......: 

TECHNICAL AND ZONE CONTACT:
a. Last Name ................: 
b. First Name ...............: 
c. Organization .............: 
d. Street Address ...........: 
e. City .....................: 
f. State ....................: 
g. ZIP Code .................: 
h. Voice Phone ..............: 
i. Electronic Mailbox .......: 

SERVERS:
a. Server1 Hostname .........: 
b. Server1 IP Address .......: 
c. Server2 Hostname .........: 
d. Server2 IP Address .......: 
e. Server3 Hostname .........: 
f. Server3 IP Address .......: 
g. Server4 Hostname .........: 
h. Server4 IP Address .......: 
i. Server5 Hostname .........: 
j. Server5 IP Address .......: