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Let Us Register Your Domain Name Print these pages and click here to go back. If you would like us to register your domain name for you, please print this form, fill it out, sign it and fax to (562) 597-2926 1. Domain Name Your domain name is the address you will give out to your clients and prospects. It's like your phone number. This is NOT the same thing as the email service provided by your Internet Service Provider (ISP). You can use capital letters, but it makes giving your address over the phone more difficult. You may NOT use spaces. Special characters like !@#$%^&* are not allowed. Many names are already registered, so please list your top three choices below. Examples of good web addresses are: bobsmithlaw.com ohiolaw.net estateplanning.com First Choice ____________________________________ Second Choice ____________________________________ Third Choice ____________________________________ 2. Billing & Administrative Contact This is you and your information. This will let you modify and control your Domain Name. Full Name ____________________________________ Company ____________________________________ Street Address 1 ____________________________________ Street Address 2 ____________________________________ City ____________________________________ State ____________________________________ Zip ____________________________________ Phone ____________________________________ Fax ____________________________________ Email ____________________________________ 3. Payment Information To register your domain name, InterNIC requires a credit card. Current cost is $70 for two years use of the name. Cardholder's Name ____________________________________ Card Type ____________________________________ Card Number ____________________________________ Expiration (Month / Year) ____________________________________ Card Billing Zip Code ____________________________________ 4. Authorization By signing below, you are authorizing us to use your credit card to register your domain name. Signature ____________________________________