It is our intention to make a voluntary contribute to ICANN in the amount of $____________.  This amount is to provide financial support to ICANN for the fiscal year July 1, 2000 through June 30, 2001.  It will be used in accordance with the Budget, posted at and adopted by the ICANN Board of Directors on 6 June 2000. 

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:    _______________________________