Domain Name and Internet Address Application
Check here for information on how to complete this form.

Domain Name Requested:____________________________________________

School Name:_____________________________________________________

School District Affiliation:_____________________________________________

School Type:__________________ Description of School:__________________

_______________________________________________________________

_______________________________________________________________

School Tech Name:________________________________________________

School Tech Title:_________________________________________________

School Tech Postal:________________________________________________

_______________________________________________________________

School Tech Phone:_________________ School Tech Fax:_________________

School Tech Mailbox:_______________________________________________

School Admin Name:_______________________________________________

School Admin Title:_________________________________________________

School Admin Postal:________________________________________________

________________________________________________________________

School Admin Phone:________________ School Admin Fax:________________

School Admin Mailbox:______________________________________________

District IT Manager:_________________________________________________

District IT Manager Postal:____________________________________________

________________________________________________________________

District IT Manager Phone:____________________________________________

District IT Manager Fax:______________________________________________

District IT Manager Mailbox:___________________________________________

Connection Type:___________________________________________________

Networked Computers:_______________ Networked Windows:______________

All Signatures must be present for application form to be accepted.

School Tech Signature:____________________________ Date:______________

School Admin Signature:___________________________ Date:______________

District IT Manager Signature:_______________________ Date:______________

Do Not Write Below This Line


Approved:______________ Authorization:__________________ Date:______________

Type: STELLAR Cable______ STELLAR SLIP______ STELLAR Null Modem _______

Other_________________________________________________________________

Network Address:_____________________ Broadcast Address:___________________

Domain Name:__________________________________________________________

STELLAR Schools footer home Previous Page