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Israel Domain Registration Form : 1.0

0. (N)ew (M)odify (D)elete....:

1. Purpose/Description........:

2. Complete Domain Name.......:

Organization Using Domain Name
3a. Organization Name..........:
3b. Street Address.............:
3c. City (& State).............:
3e. Postal Code................:
3f. Country [Israel]...........:
3g. Phone Country Code [972]...:
3h. Phone Area Code............:
3i. Phone Number...............:

Administrative Contact
4a. NIC Handle (if known)......:
4b. Name (First, Last).........:
4c. Organization Name..........:
4d. Street Address.............:
4e. City (& State).............:
4f. Postal Code................:
4g. Country [Israel]...........:
4h. Phone Country Code [972]...:
4i. Phone Area Code............:
4j. Phone Number...............:
4k. Fax Area Code..............:
4l. Fax Number.................:
4m. E-Mailbox..................:

Technical Contact
5a. NIC Handle (if known)......:
5b. Name (First, Last).........:
5c. Organization Name..........:
5d. Street Address.............:
5e. City (& State).............:
5f. Postal Code................:
5g. Country [Israel]...........:
5h. Phone Country Code [972]...:
5i. Phone Area Code............:
5j. Phone Number...............:
5k. Fax Area Code..............:
5l. Fax Number.................:
5m. E-Mailbox..................:

Service Provider or Domain Zone Contact
6a. NIC Handle (if known)......:
6b. Name (First, Last).........:
6c. Organization Name..........:
6d. Street Address.............:
6e. City (& State).............:
6f. Postal Code................:
6g. Country [Israel]...........:
6h. Phone Country Code [972]...:
6i. Phone Area Code............:
6j. Phone Number...............:
6k. Fax Area Code..............:
6l. Fax Number.................:
6m. E-Mailbox..................:

Billing Contact
7a. Billing Key (if known).....:
7b. Name (First, Last).........:
7c. Organization Name..........:
7d. Street Address.............:
7e. City (& State).............:
7f. Postal Code................:
7g. Country [Israel]...........:
7h. Phone Country Code [972]...:
7i. Phone Area Code............:
7j. Phone Number...............:
7k. Fax Area Code..............:
7l. Fax Number.................:

Domain Name Server(s)
8a. Domain Server Hostname.....:
8b. Domain Server Netaddress...:
8a. Domain Server Hostname.....:
8b. Domain Server Netaddress...:
8a. Domain Server Hostname.....:
8b. Domain Server Netaddress...: