.BANK Request Form

Registrant Contact Information Please provide the primary banking contact that will be responsible for the registration of the .BANK domain. This must be a full time employee of the Bank/Organization. This contact must also have authority to act on behalf of the bank to register a domain. This may NOT be a contract employee. This information will be verified by Symantec during the registration process.

Full Name *

Legal Name of Bank or Banking Organization *

Title

Street Address*

Street Address 2

City *

State/Province*
Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Labrador Manitoba New Brunswick Newfoundland Nova Scotia Nunavut North West Terr. Ontario Prince Edward Is. Quebec Saskatchewen Yukon
Postal Code*

Contact Email Address*

Main Phone Number*

Fax

Human Resources Contact Information Please provide a Human Resources Contact and an Immediate Manager or Supervisor Contact that will be able to verify the Registrant Contact Information provided above.

Contact Name*

Email Address*

Phone Number*

Manager Contact Name*

Manager Email Address*

Manager Phone Number*

Affiliations and Regulatory Information (if applicable) Additional Information to help expedite the verification process of your bank to register the .BANK domain. These are only to be filled out if applicable.

Banks Regulatory Agency A The agency that you are registered with in your location that helps identify that you are a legal bank, i.e. The Federal Reserve.

Regulatory ID Number A number provided to you to identify your bank, this could be a routing number or federal reserve number.

List any National Banking Organizations you or your employer are a member of: National organizations you or your bank may be a member i.e. Associations such as the American Bankers Association, National Bankers Association, etc.

List any State Banking Organizations you or your employer are a member of: State organizations that you or your bank may be a member i.e. Massachusetts Bankers Association, Connecticut Bankers Association, etc.

Additional Primary .BANK Domains If you are interested in additional .BANK domains, please list them below. All Primary domains listed will be submitted for initial submission.

 .BANK  -->
 .BANK  -->
 .BANK  -->
 .BANK  -->
 .BANK  -->
 .BANK  -->
 .BANK  -->
 .BANK  -->
 .BANK  -->

Additional  Fallback .BANK Domains For each Primary domain you may specify a Fallback domain.  If you are interested in specifying more than one Fallback domain for a given Primary domain, please contact Dovetail to submit additional fallback names.  Fallback domains are only submitted if the related Primary domain is NOT awarded.

 .BANK
 .BANK
 .BANK
 .BANK
 .BANK
 .BANK
 .BANK
 .BANK
 .BANK