Corporate Services Sign-up & Domain-Name Registration Form

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Organization Using Domain Name
Organization Name:
Street Address:
City, State, & Zip
Country
Administrative Contact
NIC Handle (if known):
Name (Last,First):	Individual Role (individual or role?)
Organization Name:
Street Address:
City, State, & Zip
Country
Phone Number
Fax Number	optional
E-Mailbox
Billing Contact
If identical to Admin Contact, check this box and skip the rest of this section:
NIC Handle (if known)
Name (Last, First):	Individual Role (individual or role?)
Organization Name:
Street Address:
City, State, & Zip
Country
Phone Number
Fax Number	optional
E-Mailbox

A domain name registration fee of $70.00 US is applicable and not covered by the Panix set-up fee. This charge will cover the $35.00 maintenance fee for two (2) years and should be paid directly to the InterNIC (Network Solutions, Inc.). After the first 2 years, the InterNIC will charge $35.00 per year to renew the domain name.