Expression of Interest Request Form

This is a request form only. All requests made through this process will be reviewed, but filing a request does not guarantee a license. Requests will be reviewed against available names and eligibility requirements. All information submitted is subject to review for accuracy, and additional information may be required. 

By completing the form below, you are providing information for review and verification purposes only.  All fields required:

First Name of Requestor:
Last Name of Requestor:
Company Name:
Address:
Address Line 2:
State/Province/Region :
City:
Country:	(select country) Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovinia Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (Dem. Republic) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey and Alderney Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Island of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (Democratic Republic of) Korea (Republic of) Kosovo Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldavia Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua-New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Re union Republic of Dominica Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay USA Uzbekistan Vanuatu Vatican (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe
Postal/Zip Code:
Email Address:
Re-Enter Email Address:
Primary Phone Number:
Alternate Phone Number:
Domain Names of Interest:	In the field above, list the Domain Names you wish to apply for in .MED (separate each by a comma if more than one).
Please confirm that you are aware this request is not guaranteed:
Digital Signature
Security code:	Enter security code: