{{heading}} - Order Form
Congratulations on your decision to move forward with your business and register your own domain name. Upon completing the form below, you will be brought to a second page where you may verify that all of the information you have provided is correct. After you approve the information, simply click the "Order It!" button and you're done.
{{syntax_error_msg}}
{{CC_FIELDS}}
{{AUTO_RENEW}}
Domain Information
Domains:
Registration Period: (min 2 years for .us)
Profile: {{reg_profile}}
{{CUSTOM_TECH_CONTACT}} {{CUSTOM_NAMESERVERS}}
Registration Type: {{reg_type_text}}
.US Nexus Information
Domain Name Application Purpose
Nexus Category of Applicant (please choose one) Category 1 - A natural person:
Who is a United States citizen
Who is a permanent resident of the United States of America or any of its possessions or territories

Category 2 - U.S. Corporation
U.S. organization incorporated within one of the 50 states of a U.S. territory

Category 3 - Bona Fide U.S. Presence
Regularly engages in lawful activities (sales of good or services or other business, commercial or non-commercial, including not-for-profit relations in the United States).
Entity has an office or other facility in the U.S.
Country of Citizenship: (required for Category 3)  
Owner Contact Information
First Name:
Last Name:
Organization Name:
Street Address:
*optional* (eg: Suite #245):
*optional* Address 3:
City:
State:
Country:
Postal Code:
Phone Number:
(eg. +1.4165551122x333)*
*optional* Fax Number:
(eg. +1.4165551122)*
Email:
Must be currently valid address
Admin Contact Information
Same as Owner Information
First Name:
Last Name:
Organization Name:
Street Address:
*optional* (eg: Suite #245):
*optional* Address 3:
City:
State:
Country:
Postal Code:
Phone Number:
(eg. +1.4165551122x333)*
*optional* Fax Number:
(eg. +1.4165551122)*
Email:
Must be currently valid address
Billing Contact Information
Same as Owner Information
Same as Admin Information
If both checkboxes are selected, 'Owner Information' checkbox will be default.
First Name:
Last Name:
Organization Name:
Street Address:
*optional* (eg: Suite #245):
*optional* Address 3:
City:
State:
Country:
Postal Code:
Phone Number:
(eg. +1.4165551122x333)*
*optional* Fax Number:
(eg. +1.4165551122)*
Email:
Must be currently valid address


* - Phone and fax formats are as follows (extention is optional):
    +{country_dialing_code}.{phone_number}[x{extension}]
    eg. "+44.02055511928"