The 1-Stop Cure-All Domain Registration Form
Brought to you by the staff of Animus Communications

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Reseller Information

Your E-mail Address:
Your Name:
Reseller's Domain Name:

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New Domain Information

Domain Name:
Organization Name:
Organization Address:
City, State & Zip:
Country:
Purpose of Domain:

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Administrative Contact Information

Contact NIC Handle:	- OR - Check here if you want Animus to be the administrative contact.
Type of Contact:	Individual Role
Note:	The rest of the contact information section should only be filled out if a contact has never been assigned a NIC handle. You can look up a contact's NIC handle by searching the whois database
Name (last, first):
Organization:
Street Address:
City, State & Zip:
Country:
Phone Number:
Fax Number:
E-Mail:

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Technical Contact Information

Contact NIC Handle:	- OR - Check here if you want Animus to be the Technical contact.
Type of Contact:	Individual Role
Note:	The rest of the contact information section should only be filled out if a contact has never been assigned a NIC handle. You can look up a contact's NIC handle by searching the whois database
Name (last, first):
Organization:
Street Address:
City, State & Zip:
Country:
Phone Number:
Fax Number:
E-Mail:

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Billing Contact

Contact NIC Handle:
Type of Contact:	Individual Role
Note:	The rest of the contact information section should only be filled out if a contact has never been assigned a NIC handle. You can look up a contact's NIC handle by searching the whois database
Name (last, first):
Organization:
Street Address:
City, State & Zip:
Country:
Phone Number:
Fax Number:
E-Mail: