XGEN Technologies Sdn Bhd

Domain Name Registration Form

To Apply for our Domain Name Registration Services, kindly fill in the form below
and click the Submit Button when you are done.

(* Required Fields)

Domain Name Details:

Domain Name *

www.
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Administrative Contact Details

Administrative Contact Code: (if existing MYNIC Contact)
Full Name *
Company Name (for Corporate Clients)
E-mail Address *
Mobile Number
Telephone Number *
Fax Number
Street Address *


City / State *
Postcode / Zipcode *
Country *

Technical Contact Details

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Technical Contact Code: (if existing MYNIC Contact)
Full Name
Company Name (for Corporate Clients)
E-mail Address
Mobile Number
Telephone Number
Fax Number
Street Address


City / State
Postcode / Zipcode
Country

Billing Contact Details

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Billing Contact Code: (if existing MYNIC Contact)
Full Name
Company Name (for Corporate Clients)
E-mail Address
Mobile Number
Telephone Number
Fax Number
Street Address


City / State
Postcode / Zipcode
Country

Service Application Details:

Hosting Packages *

[ Check out details of packages offered! ]

Preferred Web Server Operating System
Windows Linux

Name Server Details:

If you have selected to use your own Web Host (as selected above), please specify the DNS server details here:

Primary Name Server:
Primary Name Server IP:
Secondary Name Server:
Secondary Name Server IP:

Miscellaneous:

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I confirm that all information given above is true and complete. I hereby authorise XGEN Technologies Sdn. Bhd. to verify the information from whatever sources and by whatever means that XGEN Technologies Sdn. Bhd. may consider appropriate. I confirm that I shall be subjected to the rules and regulations governing the use of the applied service(s). I understand that XGEN Technologies Sdn. Bhd. reserves the right to reject any application without any due reason or terminate any existing account if the information provided herein is incorrect.

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