urbancom.net - New Domain Name Application

PLEASE PRINT IF COMPLETING THIS FORM BY HAND

Complete this form to apply for a NEW domain name. If the domain name already exists and you want it transfered to urbancom.net, complete a Domain Name Transfer Form. We can only accept applications using this form for .com and .org domain types. Any other domain types must be processed by contacting our office directly.

Domain Name: (the more choices you enter the better chance of getting the one you want)

Organization (Registrant) Information

Organization Name:

Organization Address:

City, State & Zip:

Phone Number:

Fax Number:

What products or services does your organization offer:

What do you plan to use the domain for:

Contact Information

Administrative Contact:

Name (last, first):

Organization:

Street Address:

City, State & Zip:

Phone Number:

Fax Number:

E-Mail:

Billing Contact:

Same as Administrative Contact or complete the following:

Name (last, first):

Organization:

Street Address:

City, State & Zip:

Phone Number:

Fax Number:

E-Mail:

SETUP FEES: The domain name registration and set-up fee is $100.00. Payment must be made at the time the registration is submitted. Please provide a credit card that we can charge the $100.00 fees to. You must provide us with the card number BEFORE we can order the name.

Visa MasterCard

Credit Card Number: Expiration Date: Name on Card: Credit Card Billing Zip Code:

The undersigned hereby represents and warrants to Urban Communications, Inc., an Illinois Corporation, that he represents the applicant and submits this application with the applicant's approval, and that none of the domain names the applicant is requesting for registration with the Domain Registrar infringe upon, conflict with, or otherwise violate the rights of others, including, without limitation, any service mark, trademark, trade name, and/or copyright. Applicant agrees that it shall indemnify, defend, and hold harmless Urban Communications, Inc. and its officers, directors, employees, agents, and shareholders from and against any costs, expenses (including, but not limited to, attorneys' fees and expenses), losses, damages, suits, claims, or liabilities arising out of, in connection with, or relating to the applicant's use of the domain names applied for hereunder. Urban Communications, Inc.'s application to the Domain Registrar for the applicant's use of any such domain names is done with the express approval of the applicant. The undersigned also has read the Terms of Service and the applicant agrees to operate the domain in accordance with those terms.

In addition, the undersigned authorizes Urban Communications, Inc. to charge the setup fee for the domain to the above credit card, and authorizes the use of the credit card number to make payment to the Domain Registrar for the registration fee for the requested domain name.

By: _______________________________________(Name)

Its: _______________________________________(Title)

Our fax: 708-687-8786

Mailing Address:
Urban Communications, Inc.
Domain Administration Department
5320 W. 159th St. - Suite 503
Oak Forest IL 60452-3335

Organization (Registrant) Information
Organization Name:
Organization Address:
City, State & Zip:
Phone Number:
Fax Number:
What products or services does your organization offer:
What do you plan to use the domain for:

Contact Information
Administrative Contact:
Name (last, first):
Organization:
Street Address:
City, State & Zip:
Phone Number:
Fax Number:
E-Mail:
Billing Contact:
`Same as Administrative Contact or complete the following:`
Name (last, first):
Organization:
Street Address:
City, State & Zip:
Phone Number:
Fax Number:
E-Mail:

Visa MasterCard
Credit Card Number:	Expiration Date:	Name on Card:	Credit Card Billing Zip Code: