Version 1.3

GNSO - Registrar Constituency Membership Form
The Registrar Constituency of the Generic Names Supporting Organization (“GNSO”) is one of the initial constituencies of the GNSO. The purpose of the Registrar Constituency is to represent the views and interests of ICANN Accredited domain name Registrars within the GNSO in all matters and issues of its responsibility according to ICANN bylaws.

If your company is an ICANN Accredited Registrar according to the authoritative list maintained by ICANN, and is interested in joining the Registrar Constituency, you must complete this form and designate a single representative to vote on your company’s behalf. You may provide a list of additional representatives that you may wish to be included in the mailing lists and other correspondence.



________________________________	________________________________
(Registrar Name as listed with ICANN)	(Registrar d/b/a/ name)


________________________________ 	_________________________________
(Company Voting Representative) 	(Representative’s Email Address)


________________________________ 	_________________________________
(Other Representative)			(Representative’s Email Address)


________________________________ 	_________________________________
(Other Representative)			(Representative’s Email Address)


________________________________ 	_________________________________
(Other Representative)			(Representative’s Email Address)


___________________________________
(Company Official Submitting Application)


___________________________________
(Title)


_____________________
(Date)
 

You will be notified by email upon completion of the verification and processing of your application. Your Membership will not become active until receipt of the joining fee of $750 USD. Please indicate the method you will be using to make this payment:

_____ Check by Mail

_____ Wire Transfer

To make your payment by mail send to:

Mailing Contact:  
Donna McGehee
BulkRegister, LLC
10 East Baltimore St., 10th floor
Baltimore, MD 21202
dmcgehee@bulkregister.com 
1-410-735-3561
FAX:  1-410-735-3417

To make your payment by Wire Transfer:

Bank Contact for Wires: 
Wire transfer details will be sent to you. If you have not received them contact:

dmcgehee@bulkregister.com OR rconnell@psi-japan.com