(2004-2005 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 2004 through 30 June 2005.  It will be used in accordance with the Budget, posted at and adopted by the ICANN Board of Directors on 23 July 2004. 

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:    ________________________________