DOMAIN REGISTRATION FORM Please complete this form in full to register your .CA domain. You may search for domain availability at www.canreg.com Please note that registrations will only be processed once the form and payment have been received. CanReg.com cannot guarantee that the name you are applying for will still be available at the time this application is received. IMPORTANT - Please make cheques payable to our parent company: Infinet Communications Group ONWERSHIP INFORMATION Domain Name : Legal Owner : Term (Years) : Last Name : First Name : Address : City : State/Province : Country : Zip/Postal Code : Phone : Fax : Email : ADMIN / BILLING CONTACT INFORMATION Primary Host : Primary IP : Seconday Host : Secondary IP : DOMAIN NAME SERVER INFORMATION If you are unsure of your DNS settings or have not yet found a hosting provider leave these fields blank to recieve a free under construction page. DNS may always be updated any time without charge. REGISTRATION PRICING INSTRUCTIONS CanReg.com Suite 104 - 12761 16th Ave Surrey, B.C. V4A 1N2 http://www.canreg.com [email protected] CANREG CONTACT INFO AUTHORIZATION I certify that I am an authorized signatory for the registration of this domain name and agree with the registration terms specified at http://www.canreg.com/agree Signature : Date : MULTI-YEAR DISCOUNTS TERM (Years) PRICE/YR (CAD$) TOTAL (inc. H ST) 1 Year 2 years 5 years 10 years $29.95 $24.95 $19.95 $16.95 $33.54 $55.89 $111.72 $189.84 canReg.com AN INFINET.NET DIVISION 2 1 5 10 (standard)