.NU Domain Corporate Account Application

Please print out and complete this application form so that we may begin our credit review. Fax your completed application directly to .NU Domain Ltd: Attn: Accounting Dept. Fax: +1 508-242-9712 Applicant's name Title Date     Company Date of Incorporation       Address City State/ Province Postal Code Country Phone Number Fax Number       Email Address Billing Email Address       Number of Employees Company Annual Revenue         Please describe your primary product/service or what your company does: Please indicate how you will remit payment: ________ Bankwire ____________Bankcheck ___Visa____Master Card #___________________________Exp Date ________ Cardholder Name___________________________________   Credit References (please supply minimum of 3 references) (or attach references to application) Name Street City/State Phone Acct# Name Street City/State Phone Acct# Name Street City/State Phone Acct#   Bank References (please supply minimum of 2 references) (or attach references to application) Name Street City/State Phone Acct# Name Street City/State Phone Acct# Fax application to: Attn:Accounting Dept. .NU Domain +1 508-242-9712 Mail Application: Accounting Dept. .NU Domain Main St./ Suite 31 Medfield, MA 02052