US Domain Delegation Form - Dimentech.com

US Domain Delegation Form - Dimentech.com

Sections or fields of this form marked with an asterisk (*) are required. There is no fee to request a nameserver delegation for a fourth level domain.

1.REGISTRATION TYPE
2.*FULLY-QUALIFIED DOMAIN NAME:
2a.Name:
3.*ORGANIZATION INFORMATION
3a.Organization Name.....:
3b1.Address Line 1........:
3b2.Address Line 2........:
3c.City..................:
3d.State.................:
3e.Zip/Code..............:
4.DESCRIPTION OF ORG/DOMAIN:
4a.Desc:
5.Date Operational......:
6.ADMINISTRATIVE CONTACT OF ORG/DOMAIN
6a.*Name..................:
6b.Organization Name.....:
6c.Address Line 1........:
6c.Address Line 2........:
6e.City..................:
6f.State.................:
6g.Zip/Code..............:
6h.*Voice Phone...........:
6i.*Electronic Mailbox....:
7.TECHNICAL AND ZONE CONTACT
7a.*Name..................:
7b.Organization Name.....:
7c.Address Line 1........:
7c.Address Line 2........:
7e.City..................:
7f.State.................:
7g.Zip/Code..............:
7h.*Voice Phone...........:
7i.*Electronic Mailbox....:
8.PRIMARY SERVER: HOSTNAME, NETADDRESS
8a.*Hostname..............:
8b.*IP Address............:
9. *SECONDARY SERVER: HOSTNAME, NETADDRESS
9a.*Hostname..............:
9b.*IP Address............:
10.NOTES
10a.Notes.................: 
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By submitting this request, you agree to comply with the following:

a. usTLD Dispute Resolution Policy and Rules
   http://www.nic.us/policies/docs/usdrp.pdf

b. The usTLD Nexus Requirements
   http://www.nic.us/policies/docs/ustld_nexus_requirements.pdf

c. Nexus dispute Policy and Rules
   http://www.nic.us/policiesdocs/nexus_dispute_policy.pdf

d. Registration Review Policy
   http://www.nic.us/policies/index.html

e. All data provided by you is, and will remain, true, correct, current
   and complete. Willful or grossly negligent provision of inaccurate
   or unreliable information, its willful or grossly negligent failure
   promptly to update information shall constitute a material breach of
   the Registration Agreement and may serve as the basis for cancellation
   of this registration.

By submitting this request, you understand that:

a. Registrant contact data will be made available through a publicly
   accessible WHOIS database.