Please print this form out and fax it to:  703-742-9552

(Your Company Logo)
Date:
Organization (Co.) Name:
Postal Address:
Phone Number:
Fax Number:

To InterNIC Registration Services:

The purpose on this letter is to authorize request number NIC-______________.
(INCLUDE TRACKING NUMBER ABOVE)

Statement of authority
I, the undersigned, have authority to bind this organization legally.

______________________________
Signature of individual who can legally bind the registrant
Title
Phone Number