domain registration form

canReg.com
AN INFINET.NET DIVISION
DOMAIN REGISTRATION FORM
INSTRUCTIONS
ONWERSHIP INFORMATION
Domain Name :
Legal Owner :
Term (Years) :
2
(standard)
1
5
10
ADMIN / BILLING CONTACT INFORMATION
Last Name :
First Name :
Address :
City :
State/Province :
Country :
Please complete this form in full to register
your .CA domain. You may search for
domain availability at www.canreg.com
Please note that registrations will only be
processed once the form and payment
have been received. CanReg.com cannot
guarantee that the name you are applying
for will still be available at the time this
application is received.
IMPORTANT - Please make cheques
payable to our parent company:
Infinet Communications Group
REGISTRATION PRICING
MULTI-YEAR DISCOUNTS
TERM
(Years)
PRICE/YR
TOTAL
(CAD$)
(inc. H ST)
1 Year
$29.95
$33.54
Zip/Postal Code :
2 years
$24.95
$55.89
Phone :
5 years
$19.95
$111.72
10 years
$16.95
$189.84
Fax :
Email :
DOMAIN NAME SERVER INFORMATION
Primary Host :
Primary IP :
Seconday Host :
Secondary IP :
If you are unsure of your DNS settings or have not
yet found a hosting provider leave these fields blank
to recieve a free under construction page. DNS may
always be updated any time without charge.
CANREG CONTACT INFO
CanReg.com
Suite 104 - 12761 16th Ave
Surrey, B.C.
V4A 1N2
http://www.canreg.com
[email protected]
AUTHORIZATION
I certify that I am an authorized signatory
for the registration of this domain name
and agree with the registration terms
specified at http://www.canreg.com/agree
Signature :
Date :