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23 West Fourth St., Bethlehem, PA 18015 Please print out and complete the entire form and fax or mail to the above fax # or address. I am the Administrative Contact (or Registrant) for the Internet second-level domain names listed below (the "Domain Names"). As such, I hereby authorize and direct Nic's ICANN accredited Registrar, Domain Bank, Inc. to take any and all actions required to change the designated sponsoring Registrar with respect to all of the Domain Names to Domain Bank. I hereby represent and warrant to Domain Bank that I have the full right and authority to request such changes for the Domain Names. Listed below is my credit card, which I authorize Domain Bank to use to charge for this transaction upon completion. There is a fee of $35.00 for NIC.net customers to transfer each domain name, which includes a twelve-month extension to your domain name registration. Thank you. (Please print legibly) Printed name of Contact Person Requesting Change (if different from Domain Name Owner) ___________________________________ Phone No.: ___________________________________ Credit Card Holder's Signature: ___________________________________ Credit Card Holder's Printed Name: ___________________________________ Credit Card Billing Address: ___________________________________ ___________________________________ ___________________________________ Phone No.: ___________________________________ Card Number: ___________________________________ Expiration Date: ___________________________________ Today's Date: ___________________________________ List Domain Name(s) below (use second page if required): Notes and additional information (if needed):
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