PNINA Certification Application Form

Applicant Information

Full Legal Name of Applicant

VAT Corporation Number:

Mailing Address (No PO Box Please):

Building Number:

Street:

City:

Country:

Email address of Applicant:

Telephone number and area code:

Facsimile number and area code:

Name of Administrative Contact

Full Name:

Mailing Address:

Telephone number and area code:

Facsimile number and area code:

Email address:

Mobile Number:

Name of Technical Contact

Full Name:

Mailing Address:

Telephone number and area code:

Facsimile number and area code:

Email address:

Mobile Number:

Name of Billing Contact

Full Name:

Mailing Address:

Telephone number and area code:

Facsimile number and area code:

Email address:

Mobile Number:

Website address of Applicant:

Applicant's principal bank account or financial institutions:

Please indicate

How long Applicant has been in existence:

The principal business of the Applicant:

Write down a three-line paragraph (less than 25 words) that describes your company and services you provide. This passage will be displayed along with your contact information on PNINA certified Registrars web page:

Left 25 words

I certifies that the information given in this Application is correct and complete.

Palestinian National Internet Naming Authority (PNINA)

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PNINA Certification Application Form

Mailing Address (No PO Box Please):

Please indicate