INTENTION TO CONTRIBUTE (PLEDGE CARD)
(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 http://icann.org/financials/budget-fy04-05-06oct04.html 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:    ________________________________