INTERIM .US DOMAIN TEMPLATE V2.0 Name (of individual submitting request) E-mail (of individual submitting request) 1. REGISTRATION TYPE (N)ew (M)odify (D)elete..: 2. FULLY-QUALIFIED DOMAIN NAME: 3. ORGANIZATION INFORMATION 3a. Organization Name.....: 3b. Address Line 1........: 3b. Address Line 2........: 3c. City..................: 3d. State.................: 3e. ZIP Code..............: 4. DESCRIPTION OF ORGANIZATION/DOMAIN: 5. Date Operational......: 6. ADMINISTRATIVE CONTACT OF ORGANIZATION/DOMAIN 6b. Whole Name............: 6c. Organization Name.....: 6d. Address Line 1........: 6d. Address Line 2........: 6e. City..................: 6f. State.................: 6g. ZIP Code..............: 6h. Voice Phone...........: 6i. Electronic Mailbox....: 7. TECHNICAL AND ZONE CONTACT 7b. Whole Name............: 7c. Organization Name.....: 7d. Address Line 1........: 7d. Address Line 2........: 7e. City..................: 7f. State.................: 7g. ZIP Code..............: 7h. Voice Phone...........: 7i. Electronic Mailbox....: 7j. Registration Mailbox..: 7k. Fax Number............: 8. PRIMARY SERVER: HOSTNAME, NETADDRESS 8j. Hostname..............: 8k. IP Address............: 9. SECONDARY SERVER: HOSTNAME, NETADDRESS 9a. Hostname..............: 9b. IP Address............: (repeated 9 as many times as required) 10. US NEXUS REQUIREMENTS 10a. Application Purpose...: 10b. Nexus Category........: 10c. Nexus Validator.......: --------Everything below this line may be removed before submitting--------- Instructions for completing US Nexus requirements: 10a. Application Purpose The registrant must indicate their intended use of the domain by selecting one of the following categories: (i) business for profit, (ii) non-profit business, association, religious organization, club, etc., (iii) personal use, (iv) educational purposes, or (v) government purposes 10b. Nexus Category The US Nexus requirement specify that all registrants must fall into one of the following categories to register in the usTLD: (1) A natural person (i) who is a United States Citizen (category 11),or (ii) who is a permanent resident of the United States of America or any of its possessions or territories (category 12). (2) A U.S. organization incorporated within one of the fifty (50) U.S. states, the District of Columbia, or any of the United States possessions or territories or organized or otherwise constituted under the laws of the United States of America, the District of Columbia or any of its possessions or territories or a U.S. federal, state, or local government entity or political subdivision thereof (category 21). (3) An entity of organization that has a bona fide presence in the United States of America or any of its possessions or territories that (i) Regularly engages in lawful activities (sales of goods or services or other business, commercial or non-commercial, including not-for-profit relations in the United States) (category 31), or (ii) has an office or other facility in the U.S. (category 32). 10c. Nexus Validator For Nexus category #3 (i.e.-categories 31 and 32) provide the 2-character ISO country code for the Applicant. For all other Nexus categories, leave this field blank.