CAREGISTRATION.COM - CA Registration Form

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	Step 3: Instructions To Confirm With CIRA
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Canadian Federation of Independent Business

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International
Inc.

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Domain Name Registration Form

To Register More Than One Domain Names, Click Here.
Please Complete The Following. Required Fields Marked In Red.

Organization Information

Registrant Name:

(i.e. Company Name or Individual Name)

Organization Type:
(Please Choose One)

Registration Requirements

Description Of Registrant (optional):

Brief Description (< 250 Characters Of The Domain Name )

Domain Name To Register:

Please Enter Your Domain Name And Select The Extension From The Drop-Down Menu.

Is The Submitted Domain Name A Trademark?:

Yes
No

Number Of Year(s) The Domain Name Will Be Registered:

Please Choose Term

Domain Name Server Information:

	Use Add Value International Server Information. (If You Have Not Yet Develop Your Web Site Or Do Not Have A Hosting Provider, Please Use Our Server Information.)
	Other ISP - If Other, Please Erase And Fill In Your ISP Info Below.
	DNS1 Name	IP Address
	DNS2 Name	IP Address
	DNS3 Name	IP Address
	DNS4 Name	IP Address
	DNS5 Name	IP Address
	DNS6 Name	IP Address

Administrative Contact

First Name:

Important Information

Last Name:

Nationality:

Company Name:

Job Title:

Preferred Language:

Business Phone:

Area Code : Phone: Important Contact Informaton
Please Include your Extension.

Fax Number:

Area Code : Fax :
Please Include Your Area Code.

Other Phone :

Area Code : Phone:
Please Include Your Area Code.

Mobile Phone :

Area Code : Phone:
Please Include Your Area Code.

Primary E-mail:

Please Provide An Active Valid Email Address For Your Domain Name Confirmation And Any Information Will Be Sent To.

Secondary E-mail:

Please Provide A Backup Email Address In Case Your Primary Email Is Not Functioning.

Mailing Address:

Suite or Unit Number (If Applicable)

(i.e., Suite 111, Unit 111)

City:

State/Province:

If Outside Canada

Zip/Postal Code:

Country:

Technical Contact

NOTE:

	Use Add Value International Inc. As Technical Contact (If You Do Not Have A Technical Person, Please Use Add Value International As Your Technical Contact.)
	Use Another Contact Name (If The "Other" Button Is Chosen, Please Erase And Provide Us Your Contact Info Below.)

First Name:

Last Name:

Company::

(If Different From Above, Fill Out The Following)

Job Title:

Preferred Language:

Business Phone:

Area Code : Phone:
Please Include your Extension.

Fax Number:

Area Code : Fax :
Please Include Your Area Code.

Other Phone :

Area Code : Phone:
Please Include Your Area Code.

Mobile Phone :

Area Code : Phone:
Please Include Your Area Code.

Primary E-mail:

A Valid Email Address Is Required For Any Technical Corespondents.

Secondary E-mail:

A Backup Email Address Is Required For Any Technical Corespondents.

Mailing Address:

	Same As The Administrative Contact
	A Different Address

Mailing Address:

Suite or Unit Number (if applicable):

(i.e., Suite 111, Unit 111)

City:

State/Province:

If Outside Canada

Zip/Postal Code:

Country:

For Your Security Your Ip Address Is:

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Powered By:
Add Value
International
Inc.