Locality Interim Registration Template v1.0

      1.   ORGANIZATION INFORMATION 
           Please indicate if your organization is
           (1) a state or local government entity  
           (2) an entity authorized by a state or local government entity to 			   request registration of domain names  

      1a.  Organization Type...........*:

      2.  Domain Name Requested
      2a.  Domain Name.................*:

      3.   REGISTRANT CONTACT INFORMATION
      3a.  Contact Name (Last, First)..*:
      3b.  Organization Name...........*:
      3c.  Address Line 1..............*:
      3d.  Address Line 2...............:
      3e.  Address Line 3...............:
      3f.  City........................*:
      3g.  State.......................*:
      3h.  ZIP Code....................*:
      3i.  Phone.......................*:
      3j.  Fax..........................:
      3k.  Email.......................*:

4. BILLING CONTACT INFORMATION

[Note: NeuStar does not currently charge for registration of names under this interim process.  NeuStar may establish appropriate fees in the future, subject to approval of the United States Department of Commerce.]

      4a.  Contact Name (Last, First)..*:
      4b.  Organization Name...........*:
      4c.  Address Line 1..............*:
      4d.  Address Line 2...............:
      4e.  Address Line 3...............:
      4f.  City........................*:
      4g.  State.......................*:
      4h.  ZIP Code....................*:
      4i.  Phone.......................*:
      4j.  Fax..........................:
      4k.  Email.......................*:

      5.   ADMINISTRATIVE CONTACT OF ORGANIZATION/DOMAIN
      5a.  Contact Name (Last, First)..*:
      5b.  Organization Name...........*:
      5c.  Address Line 1..............*:
      5d.  Address Line 2...............:
      5e.  Address Line 3...............:
      5f.  City........................*:
      5g.  State.......................*:
      5h.  ZIP Code....................*:
      5i.  Phone.......................*:
      5j.  Fax..........................:
      5k.  Email.......................*:

      6.   TECHNICAL AND ZONE CONTACT
      6a.  Contact Name (Last, First)..*:
      6b.  Organization Name...........*:
      6c.  Address Line 1..............*:
      6d.  Address Line 2...............:
      6e.  Address Line 3...............:
      6f.  City........................*:
      6g.  State.......................*:
      6h.  ZIP Code....................*:
      6i.  Phone.......................*:
      6j.  Fax..........................:
      6k.  Email.......................*:

      7.   PRIMARY SERVER: HOSTNAME, NETADDRESS
      7a.  Hostname....................*:
      7b.  IP Address..................*:

      8.   SECONDARY SERVER: HOSTNAME, NETADDRESS
      8a.  Hostname....................*:
      8b.  IP Address..................*:
      (repeat 8a and 8b as many times as required)

      9.   DELEGATION INFORMATION:
      9a.  Delegated Zone..............*:
      9b.  Date of Delegation (YYYY-MM)*:
      (to be completed by usTLD Administrator)

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