This form is issued by Domain Name Commission Limited (DNC or Domain Name Commission) on behalf of Internet New Zealand Incorporated (InternetNZ).

APPLICATION FOR PRE-REGISTRATION FOR REGISTRANT INFO SERVICE SEARCHES FOR DRS COMPLAINT ASSISTANCE

Please complete this form electronically, then print, sign, and return to The Domain Name Commission, at:

Domain Name Commission Limited
P O Box 11881
Wellington 6142
New Zealand

Or email to info@dnc.org.nz

1. Name of Organisation:

2. Trading Name (if applicable):

3. Name of contact person:

4. Names and details of employees if seeking to pre-register more than one person :

Complete this section if you are requesting information on behalf of an individual:

5. Name:

6. Date of birth

7. Occupation

All applicants to complete the following:

 

8. Address

9. Phone (day):

10. Phone (mobile):

11. Phone (after hours):

12. Fax:

13. Email address:

14. Evidence provided in support of the applicant's role in DRS cases and why you are seeking pre-registration;

Please describe the evidence that you are enclosing here, then attach to the hard copy of this form.

Declarations - please tick the following boxes, and sign your declaration below.

 I confirm that I am requesting this search in order to complete a .nz Dispute Resolution Service complaint;

 I will only request information where I am duly authorised to act.

 

Signed ____________________

Print name ____________________

Date ____________________