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The Saint Lucia Domain Name Registry LC

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The Pitons Saint Lucia World Heritage Site

NIC.LC Reseller Expression of Interest Form

Applicant
Name	*
(individual name, registered or official name)
Type of Applicant		Saint Lucian Citizen or Resident
		Saint Lucian Corporation or Company
		Individual
		Corporation
		Partnership
		Educational Institution
		Government organization or agency
Applicant's url (if available)
Address of Applicant

Street name	*
Suite
City	* Zip/Postal
State/Province
Country	*

Administrative contact
First name	* Middle name
Last name	*
Company Name (if different from Applicant)
Job title
Title

Phone	* Fax
Mobile phone	Other phone
Primary email	*
Secondary email

Mailing Address		Same as Applicant
		Other

Street name
Suite
City	Zip/Postal code
State/Province
Country

Technical contact
		The administrative contact is also the technical contact
		Other

First name	* Middle name
Last name	*
Company Name (if different from Applicant)
Job title
Title

Phone	* Fax
Mobile phone	Other phone
Primary email	*
Secondary email

Mailing Address		Same as the administrative contact
		Other

Street name
Suite
City	Zip/Postal code
State/Province
Country

* Required Fields

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