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INTERNET DOMAIN NAME REGISTRATION FORM

Please fill in all information and print clearly. Fax back to (806) 894-8764 for immediate processing. If you have any further questions please call Advanced Concepts at 1-800-261-3368. Please complete all pages before submitting your paperwork.

Requested Domain Name: _________________________________________________
(All domain names are limited to 22 characters. It is recommended to use 16 characters or less. All commercial domain names end with the extension ".com".)
Name will be registered to the following persons:
1. Your Name: __________________________________________________________
2. Business Name: _______________________________________________________
3. Business Street Address: ________________________________________________
4. Business City: _________________________________________________________
5. State:_________________________________________________________________
6. Zip:___________________________________________________________________
7. Country: ______________________________________________________________
8. Business Telephone: ____________________________________________________
9. Fax Number:____________________________________________________________
10. Your email address:(mandatory) ___________________________________________
11. Type of Business: ______________________________________________________

Please indicate your alternate choice below:
____ In the event that my requested name listed above is taken immediately prior to my acceptance by the NIC, I am listing a name below as my second choice:

Second Choice Domain name: ________________________________________________
___ I do not have a second choice at this time. Contact me immediately if my first choice is unavailable for registration.

I understand that MSI will handle the paperwork and the processing of the registration with the NIC. I also understand that MSI will do a preliminary search for name availability, but MSI cannot guarantee that any name will be available at the time my application is received by the NIC. There is currently an approximate 14 day backlog on registrations and there is a possibility the name I have chosen above will be taken just prior to my application. I also certify that the use of my requested name does not infringe upon any trademark or any other legal statutes. Any disputes arising after my name is registered will have to be settled between the contending parties using normal legal methods. I hold MSI and Advanced Concepts free and harmless from any liabilities or litigation that may arise from my domain name reservation.

Signature: ________________________________________

Name: ___________________________________________Date: _______________________
(print your name here)

PLEASE GO TO PAGE TWO AND COMPLETE BOTH PAGES BEFORE SUBMITTING.



DOMAIN NAME REGISTRATION, PAGE 2

DISCLAIMER
By the registration of your name on the Internet, the IANA, the InterNIC, Network Solutions Inc., the University of Southern California, MSI, Advanced Concepts, and the National Science Foundation are accepting in good faith that you have the right to use the name.

The IANA and InterNIC/Network Solutions' function in registering names on the Internet is to assure that the name does not conflict with any other name in the name space requested.

The user by the registration and use of the name and/or the continued use of an existing name, agrees, as part of their request for name registration, to indemnify and hold harmless from any and all costs, fees, and expenses arising from litigation involving trademark, trade name, service mark, and any other name infringements, or other reasons, the IANA, the InterNIC, Network Solutions Inc., the Univeristy of Southern California, MSI, Advanced Concepts, and the National Science Foundation.

The party requesting registration of this name certifies that to her/his knowledge, the use of this name does not violate trademark or other statutes and that the InterNIC will invoice them directly for an initial registration fee of $100 which pays for two years of registration.

Registering a domain name does not confer any legal rights to that name and any disputes between parties over the rights to use a particular name are to be settled betwen the contending parties using normal legal methods (See RFC 1591).

Signature: ____________________________________

Name: _______________________________________Date:_________________
(print name here)

Fax both pages to Advanced Concepts at (806)894-8764 or mail to Advanced Concepts, P.O. Box 16248, Lubbock, Texas 79490-6248.

(Please call Advanced Concepts at 1-800-261-3368 or send e-mail to staff@advancedconcepts.com if you have any questions.)

Refer to this office ID: W8


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