SCHEDULE A
If
the Registrant is not an Individual,
please print this form onto paper that displays your organization’s letterhead.
Please
note that the Authorized Representative, is deemed by CIRA to be the
authoritative agent for the Registrant that holds the domain name registration.
This individual may, among other things, vote at CIRA elections and attend CIRA
members’ meetings. Please ensure that the Authorized Representative that you
indicate on this form has the appropriate authority to carry out these
functions, both currently and in the foreseeable future.
For
ALL Registrants: Complete and sign
this form and send it to RegCA (Fax 604-533-0591) Some of the contact details that you enter in the “Administrative Contact Details” section
of this form, may be displayed to the public (along with any existing technical
contact details), in CIRA’s web-based WHOIS look-up system.
CHANGE OF ADMINISTRATIVE CONTACT
REQUEST, DECLARATION, AUTHORIZATION AND DIRECTION FORM
PART A of Schedule A
– FOR ALL REGISTRANTS
CHANGE
OF ADMINISTRATIVE CONTACT REQUEST
ADMINISTRATIVE CONTACT DETAILS
You are required to enter information in the following
12 fields. NOTE, if the information has
changed, please submit the NEW information and not the old:
1. First name:
2. Last name:
3. Preferred language (En or Fr):
4. Street address:
5. City:
6. Province:
7. Country:
8. Postal code:
9. Phone: (___)
10. Other phone (if applicable): (___)
11. Fax (if applicable): (___)
12. New email address:
Enter information for any of the following contact
details that you would also like to change/include:
13. Title (Mr, Mrs, Ms, Dr):
14. Middle name:
15. Company name:
16. Job title:
17. Cell: (___)
18. Secondary email:
PART B 2 of Schedule A - FOR REGISTRANTS THAT ARE INDIVIDUALS
Declaration, Direction and Authorization
for Change of Administrative Contact Request
To: CANADIAN
INTERNET REGISTRATION AUTHORITY
Re: CHANGE
OF ADMINISTRATIVE CONTACT REQUEST
PURSUANT TO CIRA’s POLICIES, RULES, AND PROCEDURES
I,
_______________________________, of ___________________,
_____________________________
First and last
name of Registrant City/Town/Village etc. Province/Territory/State etc.
in the country
of _______________________ am identified as
_________________________________
Country Registrant name as displayed in the CIRA WHOIS
in CIRA’s
WHOIS look-up as the Registrant for
____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Your domain names (if the
space is not sufficient, please use a separate piece of paper to list the other
domain names)
I, AS THE REQUESTER, DO HEREBY:
a) CERTIFY
THAT I am the Registrant for the domain names listed above and, if applicable,
the domain names listed on the attached sheet;
b) CERTIFY
THAT I am making this request in full compliance with CIRA’s Policies, Rules,
and Procedures;
c) CERTIFY
THAT the photo identification, shown to the witness, in support of the Change
of Administrative Contact Request is a true and valid government-issued photo
identification;
d) DIRECT AND
AUTHORIZE RegCA Enterprises Inc. and CIRA to
make the requested changes as set out above in Part A of this form;
e) CERTIFY
THAT all the information set out in this declaration, authorization, and
direction is a true and accurate statement of the facts contained herein.
DATED AT
________________________this ___________day of _________________________, 20___
City Day Month
______________________________________
Requester’s
signature
Full contact details of
Requester:
_____________________________________________________
Street
number and name
_____________________________________________________
City
_____________________________________________________
Province/State,
if applicable
_____________________________________________________
Country
_____________________________________________________
Postal
code/Zipcode, if applicable
_____________________________________________________
Phone
number
_____________________________________________________
Email
address
PART C of
Schedule A
NOTE: The Witness MUST:
1.
be a citizen of the
country that issued the valid government photo identification which is used to
verify the Requester’s identity
2.
be accessible to your
RegCA Enterprises Inc and/or CIRA for verification;
3.
have known you
personally for at least TWO years and well enough to be confident that the
statements you have made in your application form are true;
4.
sign the "Witness
Declaration for Change of Administrative Contact Request" section on your
Change of Administrative Contact Request, Declaration, Authorization, and
Direction Form;
5.
check a valid
government-issued photo identification to verify your identity
6.
be included in ONE of
the following groups:
a.
a dentist, medical
doctor or chiropractor in good standing;
b.
a judge, magistrate,
police officer (e.g., municipal, provincial or RCMP) in good standing;
c.
a lawyer (e.g., member
of a provincial bar association) in good standing;
d.
a mayor in good
standing;
e.
a minister of religion
authorized by the government to perform
marriages and who is in good standing;
f.
a notary public in good
standing;
g.
a optometrist in good
standing;
h.
a pharmacist in good
standing;
i.
a postmaster in good
standing;
j.
a principal of primary
or secondary school in good standing;
k.
a professional
accountant (member of APA, CA, CGA, CMA, PA or RPA) in good standing;
l.
a professional engineer
(e.g., P. Eng., Eng. in Quebec) in good standing;
m.
a senior administrator
in a community college (includes CEGEPs) in good standing;
n.
a senior administrator
or teacher in a university in good standing; and
o.
a veterinarian in good
standing.
Notwithstanding, the above, a notary
public in good standing, must not fulfill no. 3 above, but must meet all other
requirements. The above-noted list is
not an indication by CIRA of a person’s professional status or superior qualifications.
Witness Declaration for Change of
Administrative Contact Request
To: CANADIAN
INTERNET REGISTRATION AUTHORITY
Re: CHANGE
OF ADMINISTRATIVE CONTACT REQUEST
PURSUANT TO CIRA’s POLICIES, RULES, AND PROCEDURES
I,
____________________________, of ___________________,
_________________________________
First and last name of the Witness City/Town/Village etc. Province/Territory/State etc.
in the country
of _________________________________________ am ___________________________
Country Your group as listed above
I, AS THE WITNESS, DO HEREBY:
a) CERTIFY
THAT I am included in one of the above-noted groups and that I am in good
standing;
b) CERTIFY
THAT I have known the Requester for at least TWO years and well enough to be
confident that the statements made by the Requester are true or I am a notary
public in good standing;
c) CERTIFY
THAT I have checked the following original valid government-issued photo
identification __________________________________________ to verify the Requester’s identity and to
the best of my knowledge, the original valid government-issued photo
identification is valid and identifies the Requester;
d) CERTIFY
THAT all the information set out in this declaration is a true and accurate
statement of the facts contained herein.
DATED AT
________________________this ___________day of _________________________, 20___
City Day Month
______________________________________
Witness’s
signature
Witness's institution's,
organization's, or association's official stamp or seal
Full contact details of the
Witness:
_____________________________________________________
Street
number and name
_____________________________________________________
City
_____________________________________________________
Province/State,
if applicable
_____________________________________________________
Country
_____________________________________________________
Postal
code/Zipcode, if applicable
_____________________________________________________
Phone
number
_____________________________________________________
Email
address