You may select from the following extensions: org.qa, .sch.qa, .edu.qa, .gov.qa, .
mil.qa*. Domain Name (including extension). Password**. Registration Period ...
Domain Name Application Form
DOMAIN NAME APPLICATION FORM If you would like to register a Domain Name please carefully fill out the form below and ensure that all details provided are complete and accurate.
DOMAIN NAME(S) DETAIL You may select from the following extensions: org.qa, .sch.qa, .edu.qa, .gov.qa, .mil.qa* Domain Name (including extension)
Password**
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* Please note that relevant supporting documentation must be provided for all extensions other than .qa. ** Domain Name Password must contain between 6 and 32 characters, one letter (a-z) and one digit (0-9) and not be a word found in the dictionary. If you do not supply a Domain Name Password, one will be created for you. SUPPORTING DOCUMENTATION The following may be submitted with this application form in support of this application for a Domain Name:
Certificate of Incorporation (for org.qa, sch.qa and edu.qa extensions) A letter duly signed by the relevant government authority (for gov.qa and mil.qa extensions)
Domain Name Application Form CONTACT DETAILS REGISTRANT CONTACT DETAILS ^ Name Organisation Address Street 1 Street 2 ^ City Postcode ^ Country QATAR ^ Email Address ° Telephone Number ° Fax Number ^ Mandatory Fields ° Phone and Fax Number should be in the format +974.44995333
TECHNICAL CONTACT DETAILS Check Box to use the same details as Registrant Contact ^ Name Organisation Address Street 1 Street 2 ^ City Postcode ^ Country QATAR ^ Email Address ° Telephone Number ° Fax Number ^ Mandatory Fields ° Phone and Fax Number should be in the format +974.44995333
ADMINISTRATIVE CONTACT DETAILS Check Box to use the same details as Registrant Contact ^ Name Organisation Address Street 1 Street 2 ^ City Postcode ^ Country QATAR ^ Email Address ° Telephone Number ° Fax Number ^ Mandatory Fields ° Phone and Fax Number should be in the format +974.44995333
Domain Name Application Form BILLING CONTACT DETAILS (OPTIONAL) Check Box to use the same details as Registrant Contact ^ Name Organisation Address Street 1 Street 2 ^ City Postcode ^ Country QATAR ^ Email Address ° Telephone Number ° Fax Number ^ Mandatory Fields ° Phone and Fax Number should be in the format +974.44995333
Extension Extension
NAME SERVER DETAILS NAMESERVER 1 (Required) Host Name IP Addresses (only if Host is subordinate to Domain Name) IPv4 IPv6
NAMESERVER 2 (Required) Host Name IP Addresses (only if Host is subordinate to Domain Name) IPv4 IPv6
NAMESERVER 3 (Optional) Host Name IP Addresses (only if Host is subordinate to Domain Name) IPv4 IPv6
NAMESERVER 4 (Optional) Host Name IP Addresses (only if Host is subordinate to Domain Name) IPv4 IPv6
Domain Name Application Form DECLARATION By submitting this Application for a Domain Name, you hereby warrant that you are eligible to hold the applied for Domain Name and that all information provided in this Application is complete and accurate and is not misleading in any manner, and agree to be bound by the terms of the Registrant Agreement (attached) for the term of the Domain Name Licence Period. In the event that the information provided is found to be false, incomplete, misleading or submitted in bad faith, the attached Registrant agreement will be terminated and you will be prohibited from using the Domain Name.
Executed for and on behalf of:
..................................................................... Signature of Applicant
..................................................................... Name of Applicant (block letters)
..................................................................... Date of Application
