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