Domain Name Registration Form

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W3 Concepts, Inc. Domain Name Registration Request Form

* An Internic charge of $70.00 applies to all new Domain Name Registrations.

Contact Information:

Company/Organization:
Name:
Address:
P.O. Box:
City:
State:
Zip Code:
Country:
Phone:
Fax:

Customer Administrative/Billing Contact:

Name:
Title:
Department:
E-Mail:
Address:
P.O. Box:
City:
State:
Zip Code:
Country:
Phone:
Fax:

Domain Name:

Preferred Domain Name:
Alternate #1:
Alternate #2:

Additional Domain Name:

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Last modified: August 09, 2004