Fill and Sign the Name with Service Form

Agreement to Register Domain Name with Internet Service Provider The undersigned, __________________ , referred to in this Agreement as Registrant, represents and warrants to ____________________ , the internet service provider , a ____________ corporation and referred to in this Agreement as ISP , that none of the domain names which the Registrant is requesting for registration with ISP infringe upon, conflict with, or otherwise violates the rights of others, including, without limitation, any service mark, trademark, trade name, and/or copyright. The undersigned also agrees to abide by the Uniform Domain Name Dispute Policy, posted on ISP’s Web site as well as the Web site of the Internet Corporation for Assigned Names and Numbers, referred to in this agreement as ICANN, including any modifications from time to time. Registrant agrees to be bound by the domain name dispute policy in effect at the time of the dispute. If ISP is notified of any dispute over the domain name, Registrant agrees not to make any changes to the domain name record without ISP’s prior approval. For the adjudication of disputes concerning or arising from use of the domain name, Registrant agrees to submit, without prejudice to other applicable jurisdictions, to the jurisdiction of the courts of Registrant's domicile and the State of __________________. Registrant further agrees that its registration of the domain name is subject to suspension, cancellation, or transfer pursuant to any ICANN- adopted policy, or pursuant to any ISP or Registry procedure not inconsistent with an ICANN- adopted policy, to correct mistakes by ISP or the Registry in registering the domain name or for the resolution of disputes concerning the domain name. The term Registry is the person or entity then responsible, in accordance with an agreement between ICANN and that person or entity or, if that agreement is terminated or expires, in accordance with an agreement between the United States government and that person or entity, for providing registry services. The Registrant agrees to provide accurate and reliable contact details, and promptly correct and update them during the term of the registration. This will include the Registrant's full name, postal address, e-mail address, voice telephone number, and fax number if available, as well as the name of an authorized person for contact purposes in the case that the Registrant is an organization, association, or corporation. This will also include the IP addresses and corresponding names of the name-servers which host the domain. Finally, this will include the name, postal address, e-mail address, voice telephone number, and (where available) fax number of the technical contact and the name, postal address, e-mail address, voice telephone number, and (where available) fax number of the administrative contact for the domain. The Registrant warrants that it has provided notice to and received consent from any third parties whose contact information is provided in connection with this registration, and will provide notice and receive consent for any information from third parties provided in the future in connection with this registration. ISP is not responsible for the failure of the Registrant to receive consent from any third parties. Registrant's willful provision of inaccurate or unreliable information, willful failure promptly to update information, or failure to respond for over thirty calendar days to inquiries by ISP concerning the accuracy of contact details associated with the registration shall constitute a material breach of the Registrant-Registrar contract and be a basis for cancellation of the registration. This data may be accessed through the ISP’s Web site at [ http:// _________________ (Web site address)] . ISP requires this information to send important notices and information regarding the domain being registered and the Registrant's account. Furthermore, ISP , like every registrar, is required to provide public access to this data through a who is server and bulk access to third parties who agree not to use it to allow, enable or otherwise support the transmission of mass unsolicited, commercial advertising or solicitations via e-mail (spam) or enable high volume, automated, electronic processes that apply to ISP’s systems to register domain names. Registrant grants ISP the right to disclose to third parties (both the general public and the domain name Registry responsible for this domain) the following mandatory information that the Registrant is required to provide and keep current throughout the registration of a domain name:  The registered domain name;  Registrant's name and postal address;  The names, postal addresses, e-mail addresses, voice telephone numbers and (where available) fax numbers of the technical and administrative contacts for the domains;  The IP addresses and names of the name-servers which host the domain name;  The original creation date of the registration; and  The expiration date of the registration. ISP will only use this information to contact the Registrant in connection with Registrant's domain name registration and account and ISP and its affiliates' services and systems, as well as meet its obligations to register and host the domain, and provide third-party access to the data to meet ISP’s obligations as a registrar. ISP will take reasonable precautions to protect the Personal Data from loss, misuse, unauthorized access or disclosure, alteration, or destruction. Any Registrant that intends to license use of a domain name to a third party is nonetheless the Registrant of record and is responsible for providing its own full contact information and for providing and updating accurate technical and administrative contact information adequate to facilitate timely resolution of any problems that arise in connection with the domain. A Registrant licensing use of a domain according to this provision shall accept liability for harm caused by wrongful use of the domain, unless Registrant promptly discloses the identity of the licensee to a party providing Registrant reasonable evidence of actionable harm. The undersigned agrees that it shall indemnify, defend and hold harmless ISP , the Registry and their officers, directors, employees, agents and shareholders from and against any costs, expenses (including, among other expenses, attorneys' fees and expenses), losses, damages, suits, claims, or liabilities arising out of, in connection with, or relating to any of the undersigned's application to use the domain names applied for pursuant to this agreement, the use of any such domain names by the undersigned or any party using any such domain name with the consent of the undersigned. Registrant agrees that ISP may modify this Agreement at any time, with thirty days' notice, by posting a new agreement on the ISP ’s Web site or providing the new agreement to Registrant via the contact information Registrant has provided. If Registrant does not agree with any changes to the Agreement, Registrant may cancel this Agreement at any time by providing notice in writing to ISP _____________________ (address) or via fax at _______________ (fax number) . Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. By clicking on the I Agree button below Registrant agrees to the terms and conditions set forth in this Agreement. [ ] I Agree this the _____ day of _________________, 20_____.