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LTC Domain Transfer Request


Section 1	Reseller Information:
*Company:
*Contact:
*Contact email add:
	Login/technical information will be sent to this email unless otherwise specified
Section 2	Customer Information:
*Company:
*Contact:
*Address:
*City:
*State:		*ZIP:
*Phone:		FAX:
Section 3	Domains:	Install Options:
	Login/Technical information will be emailed to Reseller Contact Email address unless otherwise specified in comments (below).	FTP = File Transfer Protocol FP = FRONTPAGE Extensions POP = POP3 Email format EX = EXCHANGE Email format Select all applicable for each domain
*URL 1:		FTP	FPPOPEX
URL 2:		FTP	FPPOPEX
URL 3:		FTP	FPPOPEX
URL 4:		FTP	FPPOPEX
URL 5:		FTP	FPPOPEX
URL 6:		FTP	FPPOPEX
URL 7:		FTP	FPPOPEX
URL 8:		FTP	FPPOPEX
URL 9:		FTP	FPPOPEX
URL 10:		FTP	FPPOPEX
Additional URLs:

Section 4	Email Addresses:
Email Add1:
Email Add2:
Email Add3:
Email Add4:
Email Add5:
Additional Email Adds
Section 5	Registrar Information:
PBI to transfer/obtain domain(s) from Registrar? Yes No If yes, please complete this section:
*Registrar
Account #
Password
Handle
Payment Method	MC/Visa/Amex Check *prepayment required

Comments / Additional Information:
Are you interested in joining our referral program as an additional revenue stream for your company?
Yes No You may SUBMIT this Domain Request Form when you are finished or CLEAR this form to start again. After clicking the submit button, please wait until you see the Thank You message before clicking on anything else.

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