(2001-2002 Fiscal Year)

It is our intention to make a voluntary contribution to ICANN in the amount of US$____________.  This amount is to provide financial support to ICANN for the fiscal year 1 July 2001 through 30 June 2002.  It will be used in accordance with the Budget, posted at and adopted by the ICANN Board of Directors on 4 June 2001. 

We agree to pay this amount on or before:  __________________________.

This contribution is being made by the ccTLD registry listed below:

Registry Name: ___________________________________________

Two Letter Country Code:  ___________________________________

Name: __________________________________________________

Mailing Address: __________________________________________



Telephone: __________________       Fax: _____________________

E:mail address:  ___________________________________________

Signed: _______________________________       Date:  ___________________

Title:    ________________________________