1. Domain Name System (DNS) Registration for:

Full Organisation Name: (Required)

Postal Address: (Required)

Post Code: (Required)

Organisation Code: (Required)

Please enter telephone and fax numbers with no spaces eg 01139311311

Telephone Number: (Required)

Technical Contact: (Required)

Technical Contact Email: (Required)

Hostname

IP Address

1. For records visible only on N3

Example: nww.exampledomain.nhs.uk

IP Address:

must be within N3

2. For records visible on the public Internet

Example: www.exampledomain.nhs.uk

IP Address

3. For applications and sub-domains

Example: citrix.exampledomain.nhs.uk

Hostname

IP address

Please state what sort of organisation this domain is for (Required)

Example: Clinical Commissioning Group

Please outline the purpose of your site and the content you plan to publish, and please clarify any acronyms or abbreviations.

Reason (Required)

Applicants Full Name: (Required)

Telephone: (Required)

Position: (Required)

Organisation: (Required)

Email: (Required)

Important

The applicant is responsible for the accuracy of the information contained in this form. In addition to this, he/she is responsible for the impact of the organisation's network configuration and use on N3 and wider Internet. Information supplied within these forms helps to evaluate and process your request. It will be kept in confidence and is for the use of the NHS Connecting For Health and the Department of Health only. We will only disclose organisation details to approved certificate authorities for SSL purposes.