Domain Bank, Inc at 23 West Fourth St., Bethlehem, PA 18015
Please print out and complete the entire form and fax or mail to the above fax # or address.
I am the Administrative Contact (or Registrant) for the Internet second-level domain names listed below (the "Domain Names"). As such, I hereby authorize and direct 19.99domainname's Registrar, Domain Bank, Inc. to take any and all actions required to change the designated sponsoring registrar with respect to all of the Domain Names to Domain Bank. I hereby represent and warrant to Domain Bank that I have the full right and authority to request such changes for the Domain Names.
Listed below is my credit card, which I authorize Domain Bank to use to charge for this transaction upon completion. There is a fee of $19.99 for 19.99domainnames.com customers to transfer each domain name, which includes a twelve-month extension to your domain name registration.
Thank you.
(Please print legibly)
Printed name of Contact Person Requesting Change (if different from Domain Name Owner)
___________________________________
Phone No.:
___________________________________
Credit Card Holder's Signature:
___________________________________
Credit Card Holder's Printed Name:
___________________________________
Credit Card Billing Address:
___________________________________
___________________________________
___________________________________
Phone No.:
___________________________________
Card Number:
___________________________________
Expiration Date:
___________________________________
Today's Date:
___________________________________
List Domain Name(s) below (use second page if required):
Notes and additional information (if needed):
Domain Bank, Inc at 23 West Fourth St., Bethlehem, PA 18015
