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Domain Hosting Application Form
Domain Hosting Application Form
PO Box 20 Chadstone 3148 Phone: 03 9885 4655

 Domain Name Registration/Delegation
Domain Name:
First Name: Phone:
Surname: Fax:
Email Address:
   The domain name is already registered and the Domain Password is:
   We require registration of the domain name for the organisation detailed below.

 Domain Name Registration ($80 for 2 Years)
Organisation Name:
Postal Address:
Suburb:     Postcode:
 Registration Number:
Organisation Type:    ACN (Australian Company Number)
   ABN (Australian Business Number)
   RBN (Registered Business Number) State:
   Other, please explain:
Eligibility Type:    Company    Club    Religious/Church Group
   Sole Trader    Charity    Non-profit Organisation
   Registered Business    Trade Union    Incorporated Association
   Trademark Owner    Political Party    Commercial Statutory Body
   Pending TM Owner    Industry Body    Other
Claim Type:
   Name of a service which we provide    Exact match for business name or trademark
   Refers to program we administer    Abbreviation of business name or trademark
   Name of event that we sponsor    Acronym of business name or trademark
   Name of activity we teach or train    Name refers product we build or manufacture
   Refers to a venue which we operate    Name of the profession practiced by us or our employees
Please verify by clicking the "I'm not a robot" box before processing application

By clicking the Submit button below, you agree that you have read and will abide by the
Service Agreement and certify that the above details are true and correct.

Download printable version - Domain Hosting Application