(2004-2005 Fiscal Year)

It is our intention to pay ICANN the amount of US$____________ for ICANNís role in providing global services to the Internet community.† This amount is our share of financial support required by 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 within _____ days of receipt of invoice from ICANN.

This payment will be made by the ccTLD registry listed below:

Registry Name: ___________________________________________

Two Letter Country Code:† ___________________________________

Name: __________________________________________________

Mailing Address: __________________________________________



Telephone: __________________†††††† Fax: _______________________

E:mail address:† ____________________________________________

Signed: _______________________________† Date:† ______________

Title:††† ________________________________