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1. Owner type (please select one)     individual             company         organization

2. E-mail address of person completing this form:

3. The domain name being requested

4. The Applicant

4a. Name ( full legal name of the organization as it appears on legal documents):

4b. Postal Address :

4c. Telephone Nº :

4d. Telefax Nº :

5. Administrative Contact Person (This person will be the contact for all subsequent

correspondence regarding this Domain)

5a. Name :

5b. Postal Address :

5c. Telephone Nº :

5d. Telefax Nº :

5e. E-Mail Address (present e-mail address if applicable, or intended e-mail address after new domain name registration is completed):

6. Technical Contact (This person will be the technical contact point for the Domain administration. This is the contact point for operational problems concerning the Domain. If the Technical Contact is the same as theAdministrative Contact, please enter "Same as Administrative Contact").6a. Name :6b. Postal Address :

6c. Telephone Nº :

6d. Telefax Nº :

6e. E-Mail address (present e-mail Address if applicable, or intended e-mail address after new domain name registration is completed):

7.Billing contact

7a. Name :

7b. Postal Address :

7c. Telephone Nº :

7d. Telefax Nº :7e. E-Mail Address

8. Name Server Information (Please contact your Technical Contact for the relevant information)

-The Applicant must provide at least two independent servers for the

requested Domain that provide the Domain service for translating names to

IP addresses for hosts in this Domain.-In order to maintain safe Domain Name Services it is necessary to have the

Primary and the Secondary Domain Name Servers in physically separate

locations and on different networks.-These servers must be already configured and runningbefore the submission of this form.

8a. Primary Server Hostname (including Domain):8b. Primary Server IP Address:

8c. Secondary Server Hostname (including Domain):

8d. Secondary Server IP Address:

9. Optional additional Secondary Server Hostname ( including Domain):

9a. Optional additional Secondary Server IP Address:

9b. Optional second additional Secondary Server Hostname

( including Domain):

9c. Optional second additional Secondary Server IP Address:

9d. Additional Information (if you have any other information to annotate to this request please add it here):

- Incorrect or incomplete information supplied on this form may result in a Domain Name Application being rejected, or the Domain Name may be removed even after registration.

- Once this form has been submitted, you will be sent e-mail indicating that the form has been accepted, and that your request is processing.

10. By submitting your request you warrant:

- The information supplied in the request is true and correct.

- The application is made with the authority of the Applicant.

- You have read and accepted the "Regulations for Registering a Domain

Name under the Top Level Domain .kh" .

- Any changes would be required a new application and considered as new registration.

11. The party requesting registration of this name certifies that to her/his

knowledge, the use of this name does not violate trade name or other statutes. Registration of a Domain Name does not confer any legal rights to that name

and any disputes between parties over the rights to use a particular name are

to be settled between the contending parties using normal legal methods.

12. Certification

- Application form must be submitted by e-mail to dns-admin@dns.net.kh .

- License or certificate of trade name must be shown upon request by the DNS Administrator (the original copy must be presented for sighting or the photocopy is certified by the Phnom Penh municipality).

- The Domain name registration will be completed upon receipt of your initial Domain Registration Payment.

DNS Administrator

Top Level Domain .kh

Telephone number 023 725384