INTENTION TO CONTRIBUTE (PLEDGE CARD)
(2003-2004 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 2003 through 30 June 2004.  It will be used in accordance with the Budget, posted at http://www.icann.org/financials/budget-fy03-04-14aug03.htm and adopted by the ICANN Board of Directors on 26 June 2003. 

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:    ________________________________