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									                                                    Global X UK             Tel: + 0207 7900 858
                                                    162, Commercial Road    Fax:
                                                    London E1 2JY, UK       Email:
                                                                             Web: www.

        Domain Name Registration Form

    Please provide a choice of domain name that will be used to identify your company's network.
    For example, GlobalXUK domain is We recommend a domain name of the form

    If you require your domain to be registered in another top level domain e.g., .org, .net,
    .info, .us .etc… the registration process takes a little longer as registration is done through
    INTERNIC. (USA) In most cases an international presence is required for such domains.

    Please note that you are required to have domain name servers before you submit your
    registration. If you do not have Primary and Secondary name servers, Global X UK can provide
    Domain Name Services on your behalf. If you have any problems completing the form, please
    telephone GlobalXUK on (+44) 0207 7900 858 or email

    If you would like to REGISTER your DOMAIN name please fill out the following
    application form and return by email or post. (Please tick√):

       Register a new domain name         Renew my domain name   Transfer & renew my domain name

    Please provide your desired domain name (In case your first choice is unavailable please
    nominate at least four choice also)

    First Choice:     WWW.

    Second Choice: WWW.

    Third Choice:     WWW.

    Fourth Choice:    WWW.


            1 year           2 years           3 years       4 years        5 years

            6 years          7 years           8 years       9 years        10 years
     Domain Name Information
     Registrant (Organization/ Owner Name)
     First Name
     Last Name
     Email Address
     Organization Name & Address

     City                                            State
     Country                                         Post Code
     Tel No                                          Fax No.
     Home Page [optional]

     (ii) ADMINISTRATIVE CONTACT : (Please tick “√” if it is same as Registrant Information)
     Title                            Mr. / Ms. [please select one]
     Administrative First Name
     Administrative Last Name
     Email Address
     Organization Address

     City                                            State
     Country                                         Post Code
     Tel No                                          Fax No.

     (iii) TECHNICAL CONTACT : (Please tick “√” if it is same as Registrant Information)
     Title                              Mr. / Ms. [please select one]
     Technical First Name
     Technical Last Name
     Email Address
     Organization Address

     City                                            State
     Country                                         Post Code
     Tel No                                          Fax No.

     (iv) Billing Contact will default to use GlobalXUK contact information, compliance to Registry policy

D.   SPECIFY DNS SERVER (If any - Please ensure that your Name servers and IP addresses are valid)
     (i) Hostnames for your DNS Servers
     Primary DNS Server (Hostname) :
     Primary IP address               :
     Secondary DNS Server (Hostname):
     Secondary IP address             :

        Once completed this form, please e-mail this registration form to

                                TERMS AND CONDITIONS:
    1. Domain extension that are available .com .info .net .org .me .mobi .us .biz
    2. Registration term is fixed for minimum 1 year. Maximum 10 years.
    3. All domain registration will comply with INTERNIC Domain Name Registration Agreement
    4. Change of DNS settings is a chargeable service; therefore, please ensure that your Name
         servers and IP addresses are valid.
    5. Successful registered domain and hosting will manage & maintained by with us at 24/7.
    6. Domain names are subject to availability. GlobalXUK does not guarantee the success rate to
         secure all listed domain names.
    7. Should any of the registration is not successful; the registration fee of the unsuccessful domain
         name will be refund to you.        However, NO refund or deletion is allowed for successful
    8.   All Domain Name sales are final. There are no refunds, exchanges or modifications will be permitted
    9. By applying for the domain name and through the use or continued use of the domain name, the
         applicant agrees to be bound by the terms of GlobalXUK current domain name policy (Domain
         Registration Policy). The applicant acknowledges and agrees that GlobalXUK may change the
         terms and conditions of the Domain Registration Policy from time to time as provided in the
         Domain Registration Policy.
    10. It supersedes, and its terms, all prior proposals, agreements, or other communications between
         the parties. This Registration Agreement may only be amended as provided in the Domain
         Registration Policy.
    11. Your form will be processed within ten (10) business days This Registration Agreement shall be
         all respects by and construed in accordance with the laws of the INTERNIC. This Registration
         Agreement is the complete and exclusive agreement of the applicant and GlobalXUK regarding
         domain names and a confirmation email will be sent notifying you of your registration. You may
         also want to make a copy of this registration form for your records.

             YES, I have read and accepted the Domain Name Registration Agreement and policies.

5        AGREEMENT

         To our knowledge, use of the name requested for domain registration does not violate trademark
         or other statutes.

         Application completed by:       ____________________________________________________

         Signature:                      ____________________________________________________

         Date:                           ____________________________________________________


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