Domain Name Registration/Reservation Form



Domain Name Registration Application Form for the .ps Domain

Application for: ( Registration ( Renewal ( Modification

Renewal Period: ( (1) One year ( (3) Three years ( (10) Ten years

|Certified Registrar |

|Name: |PNINA Certification No. |

|Payment Method: θ Bank Deposit (Attach Slip) θ Deduct from my Credit Line |

|Applicant (Domain Owner) |

|Name: |Email: |

|Address: |Tel: |

|P.O. Box |Mobile: |Fax: |

|Administrative Contact |

|Name: |Title: |

|Address: |

|Mobile: |Tel: |

|Fax: |Email: |

|Technical Contact |

|Name: |Title: |

|Address: |

|Mobile: |Tel: |

|Fax: |Email: |

|Domain Name |Second Level Domain |

| |θ ps θ com.ps θ org.ps θ net.ps |

| |θ gov.ps θ sec.ps θ edu.ps θ plo.ps |

|Other Choices if first choice is not available: |

|1- 2- 3- |

|Domain Name Servers (Fully Qualified Host Name) |

|Primary Name Server: |IP Address: |

|Secondary Name Server: |IP Address: |

|Third Secondary Servers: |IP Address: |

|By signing this registration form, I admit that I have read, understood and agreed to be bound by Registration Policies and |

|Procedures for Registering domains under the .ps ccTLD document and the terms and conditions set in that document and PNINA |

|By-laws which can be found at PNINA website (pnina.ps). I confirm that all the information entered into this form is |

|correct and I undertake to advice PNINA about any change. |

|Certified Registrar |

|Name |Authorized Signature/Stamp |Date |

| | | |

|Applicant |

|Name |Authorized Signature/Stamp |Date |

| | | |

|For PNINA Use Only |

|Serial No: |PNINA Staff Name: |

|Date: |Time: |Status: θ APPROVED θ REJECTED |

|Comments: |

| |

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