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}}
(2 years for .uk, max 5 years for .cn)
First Name:
Last Name:
Organization Name:
Street Address:
*optional*
Address 2:
*optional*
Address 3:
City:
State/Province:
Postal Code:
Country:
{{OWNER_COUNTRY_LIST}}
Phone Number:
(eg. 416-555-1122 x333)
*optional*
Fax Number:
(eg. 416-555-1122)
Email:
Auto renew:
Yes
No
Administrative Contact Information
First Name:
Last Name:
Organization Name:
Street Address:
*optional*
Address 2:
*optional*
Address 3:
City:
State:
2 Letter Country Code:
{{ADMIN_COUNTRY_LIST}}
Postal Code:
Phone Number:
(eg. 416-555-1122 x333)
*optional*
Fax Number:
(eg. 416-555-1122)
Email:
Billing Information
First Name:
Last Name:
Organization Name:
Street Address:
*optional*
Address 2:
*optional*
Address 3:
City:
State:
2 Letter Country Code:
{{BILLING_COUNTRY_LIST}}
Postal Code:
Phone Number:
(eg. 416-555-1122 x333)
*optional*
Fax Number:
(eg. 416-555-1122)
Email:
Technical Contact Information
First Name:
Last Name:
Organization Name:
Street Address:
*optional*
Address 2:
*optional*
Address 3:
City:
State:
2 Letter Country Code:
{{TECH_COUNTRY_LIST}}
Postal Code:
Phone Number:
(eg. 416-555-1122 x333)
*optional*
Fax Number:
(eg. 416-555-1122)
Email:
DNS Information
Primary DNS Hostname:
Secondary DNS Hostname:
*optional*
Third DNS Hostname:
*optional*
Fourth DNS Hostname:
*optional*
Fifth DNS Hostname:
*optional*
Sixth DNS Hostname: