Domain Name Registration Form

Please register a domain name (companyname.com) for my organization.

I agree to pay $50.00 per domain name registration, $80.00 to RiskINFO per year for domain name hosting, and the $70.00 InterNIC fee. The registration and maintenance of domain names in the COM, NET and ORG domains are subject to registration and maintenance fees. The domain name owner is responsible for the payment of such fees to RiskINFO, which pays them to the Registrar. Any failure to pay such fees to the Registrar may result in the loss of use of the domain name.

Signature:________________________________________ Date:__________________________

Choosing a domain name

After filling in this form and submitting it electronically to expedite your request, please print it out, sign it, and send it by regular mail to:

RiskINFO
234 West Baltimore Avenue
Larkspur, CA 94939

Domain registration requests processed without receipt of a signed Agreement within 10 days will be forfeited, and a $130 processing fee will apply.

Total length must not exceed 26 characters (including ".com"). Characters can be letters, digits, and the dash. Domain names must end in one of the following: .COM is for commercial, for-profit organizations .EDU is for 4-year, degree granting colleges/universities. .GOV is for United States federal government agencies. .ORG is for miscellaneous, usually non-profit, organizations. Is this a request for a transfer of an existing domain name? yes no If this is to be a newly-registered domain name, please list your top three choices. We will register the first available entry: 1.) 2.) 3.)

Owner of the Domain

Name of Organization or Individual:
Address:
City:	State & Zip Code:

Administrative and Billing Information

No entry required if you want us to process any updates to your registration, at no additional cost.)

Contact Name:
Organization Name:
Address:
City:	State & Zip Code:
Telephone:	Fax:
Email (required):

Request a UserName for "FTP" access (lower case, first initial, no space, last name):
Request a Password (lower case, no spaces, 6-10 characters, no 1s or "el"s:

New Email address to be set up:

Do you wish for this address to be a new email box, or prefer that mail be forwarded to an existing email address?
New email box
Forward to existing email box

If "no" to above, Existing Email address to which email should be forwarded

Do you have any comments or special instructions (such as additional email boxes)? Please enter them in the space provided below:

Send in Your Domain Registration Request