dotcanuck Web Services - Mail-in Registration Form

This form is designed for those who do not use a credit card to purchase their domain name. Although every effort is made to secure the domain name you wish to register, we do not guarantee its availability.

Complete the form which follows, then print and mail it to:

TransitionalMedia Incorporated
PO Box 5263
Victoria BC V8R 6N4
Canada

All cheques or money orders must be made payable to TransitionalMedia Incorporated

Step 1 - Find Your Domain

First, enter the dot-ca address you wish to register.

Domain Name: What's this?

Step 2 - Review and Sign Contract

Click to review the Registration Agreement with dotcanuck Web Services. Please sign to indicate you have read, and agree to the Registration Agreement.

SIGNATURE __________________________________ DATE _______________

Here is some information you may wish to review prior to registration:

Step 3 - Establish dotcanuck Identity

Establish a unique identity for dotcanuck Web Services. This identity allows you to maintain several domain registrations under the same account.

Name:  What's this?

Email Address:  What's this?

Enter Password:  What's this?

Step 4 - Registrant Organization Information

Any items on this form which are marked with a red asterisk (*) are required fields.

* Registrant Name: What's this?

* Legal Classification of the Registrant: What's this?

Step 5 - Administrative Contact Information What's this?

Every domain must have and Administrative and Technical contact. If they are the same person, you need only complete the Administrative information, then indicate in Step 7 that they are identical.

* Language Preference: Nationality:

Name (first, middle, * last):

Title:

Company:

* Phone Number:			Fax Number:
Mobile Number:			Other Number:

* Primary E-mail Address:

Secondary E-mail Address:

* Street Number / Name / Type / Orientation:

Unit/Suite/Apt:

Additional Address Line:

* City:

* Postal Code:

* Country:

Step 6 - Technical Contact Information What's this?

The administrative and technical contacts are the same person.
The administrative and technical contacts are different people.

* Language Preference:

Name (first, middle, *last):

Title:

Company:

* Phone Number:			Fax Number:
Mobile Number:			Other Number:

Primary E-mail Address:

Secondary E-mail Address:

The administrative and technical contact address are the same.
The administative contact address information is below.

* Street Number / Name / Type / Orientation:

Unit/Suite/Apt:

Additional Address Line:

* City:

* Postal Code:

* Country:

Step 7 - Domain Name Information

Trademark Status: What's this?

Step 8 - Domain Name Server Information

Primary Name Server (DNS):  What's this?

Secondary Name Server (DNS):   What's this?

Primary IP:   What's this?

Secondary IP:   What's this?

Step 9 - Calculate Amount Due

Write or type the amount due in the table below. Refer to the Price Schedule table for correct amounts.

Number of Years:
Registration Cost (based on Number of Years, see Table):
Administrative Surcharge (Always $5.00 for offline registrations):	$5.00
Sub-Total (Registration Cost plus Administrative Surcharge):
HST (12% of Sub-Total):
Total Cost (Sub-Total plus GST):

Now print and mail your form with your payment according to the instructions at the beginning of this form. If you need assistance, please Contact us. Allow at least two weeks for regular cheques to be processed unless paying by money order or certified cheque.

If you are using a credit card, complete the section below:

Card Type:
Name on Card:
Card Number:
Expiry:

I approve the above transaction being billed to my credit card:

SIGNATURE __________________________________ DATE _______________