This form is issued by Domain Name Commission Limited (DNC or Domain Name Commission) on behalf of Internet New Zealand Incorporated (InternetNZ). APPLICATION FOR REGISTRANT INFO SERVICE SEARCH -.NZ NAMES FOR DISPUTE RESOLUTION SERVICE COMPLAINT Please complete this form electronically, then print, sign, and return to The Domain Name Commission, at: Domain Name Commission Limited P O Box 11881 Wellington 6142 New Zealand Or email to info@dnc.org.nz 1. Domain name/s to be subject to a DRS Complaint (maximum of 5) Complete this section if you are requesting information on behalf of an organisation: 2.Name of Organsiation: 3. Trading Name (if applicable): 4.Name of contact person: Complete this section if you are requesting information on behalf of an individual: 5. Name: 6. Date of birth All applicants to complete the following: 7. Address 8. Phone (day): 9. Phone (mobile): 10. Phone (after hours): 11. Fax: 12. Email address: 13. Evidence as to the applicant's identity and contact details (for example, a photocopy of a driver's licence) and, where appropriate, evidence as to the applicant's authority to apply for a search on behalf of a company (for example, written authorisation signed by a director of the relevant company); Please describe the evidence that you are enclosing here, then attach to the hard copy of this form. Search criteria requested Declarations - please tick the following boxes, and sign your declaration below. I confirm that I am requesting this search in order to complete a .nz Dispute Resolution Service complaint; I confirm that the information gained from this search will not be misused; If Applicable I have been authorised to make this search request on behalf of a client in relation to a .nz Dispute Resolution Service complaint Signed Print name Date