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Domain name request form

Request type
URL
Purpose and comments
(Explain the rationale for your request, including the selection of the domain name if applicable)

Organisational information

Organisation name
Communications manager
Approved by Agency Communications Manager
Postal address

Administrative contact

Name
Position
Phone
Email

Technical contact

Name
Position
Phone
Email

Customer help desk contact

Name
Position
Phone
Email

Server

DNS 1
DNS 2
DNS 3
(optional)

Invoicing details

Please acknowledge acceptance of the set-up fee of $53 (ex GST)
If this is a new account, please provide a billing address
For an existing Networking Tasmania Account, please provide your account number

Customer business contact and officer to receive invoices

Name
Position
Postal address
Phone
Email