Application for a Free .coop Domain Name Registration

Only complete this form if your organisation is eligible to register .coop domain names (click here to read the full eligibility criteria). In addition you are only eligible for a free registration if your organisation does not already have a .coop domain name.

Please note that we may contact the reference that you provide information for, in order to verify the status of your organisation.

Your first choice domain name: * http://www. .coop

Your second choice domain name: http://www. .coop

Your third choice domain name: http://www. .coop

Registration period: *

Select your preferred registration period ranging from 1 year to 10 years. Note that the free registration period is only 1 year. If you select more than 1 year the name will be registered for 1 year free of charge (subject to confirmation of your eligibility), and will then be renewed for the remaining required period, and you will be required to pay for the renewal at our normal rate.

Registrant information

Please provide the following information about the organisation that will be the owner (registrant) of the domain name.

Organisation Name: *

Name of contact person: *

Email address: *

Address: *

Town/City: *

State/Region/Province: *

Country: *

Postal Code: *

Tel. no. : *

Please include the country code, writing your telephone number as if calling from outside your country.

Fax:

If you have no fax number please leave this field blank.

Cooperative Reference

Please provide details of a separate independent organisation that can vouch for your organisation's eligibility. This must NOT be your organisation. Ideally it will be a leading national or sectoral cooperative organisation in your country.

Organisation Name: *

Contact Name: *

Email Address: *

Address: *

Town/City: *

State/Region/Province: *

Country: *