*****************************************************
  KanREN Domain Name Registration/Modification Form

      Do not modify or change the formatting
        in any way or this document cannot
                 be processed!

      Do not submit this form more than
         72 hours before you want the
            changes to take effect.

      SECTIONS 1 THROUGH 9 MUST BE COMPLETED

      NOTE: NIC handles are no longer accepted
            as the only item in sections 6 & 7,
            per Neustar rules.

      Email Completed forms to ns@kanren.net
*****************************************************

      Name:
      E-mail: 


      1.   REGISTRATION TYPE
           (N)ew (M)odify (D)elete..:


      2.   FULLY-QUALIFIED DOMAIN NAME:


      3.   ORGANIZATION INFORMATION
      3a.  Organization Name.....:
      3b.  Address Line 1........:
      3b.  Address Line 2........:
      3c.  City..................:
      3d.  State.................:
      3e.  ZIP Code..............:


      4.   DESCRIPTION OF ORGANIZATION/DOMAIN:


      5.   Date Operational (no more than 72 hours in advance)......:


      6.   ADMINISTRATIVE CONTACT OF ORGANIZATION/DOMAIN (Must be complete)
      6a.  NIChandle (if known)..:
      6b.  Whole Name............:
      6c.  Organization Name.....:
      6d.  Address Line 1........:
      6d.  Address Line 2........:
      6e.  City..................:
      6f.  State.................:
      6g.  ZIP Code..............:
      6h.  Voice Phone...........:
      6i.  Electronic Mailbox....:


      7.   TECHNICAL AND ZONE CONTACT (Must be different from ADMINISTRATIVE CONTACT)
      7a.  NIChandle (if known)..:
      7b.  Whole Name............:
      7c.  Organization Name.....:
      7d.  Address Line 1........:
      7d.  Address Line 2........:
      7e.  City..................:
      7f.  State.................:
      7g.  ZIP Code..............:
      7h.  Voice Phone...........:
      7i.  Electronic Mailbox....:
      7j.  Registration Mailbox..:
      7k.  Fax Number............:


      8.   PRIMARY SERVER:   (Must be FQDN, ex. hostname.domain.net)
      8a.  Hostname..............:
      8b.  IP Address............:


      9.   SECONDARY SERVER: (Must be FQDN, ex. hostname.domain.net)
      9a.  Hostname..............:
      9b.  IP Address............:


      10.  TERTIARY SERVER:  (Repeat as Necessary)
      10a.  Hostname..............:
      10b.  IP Address............: