Modify Domain Registration Record

NOTE: This form is ONLY for domains registered by Hazel Web Hosting.

* Domain Name:
* Email Address:	This must be the email address used to register the above domain name or the changes will not take effect.

Company
Address
City, State, Zip
Country

Complete the fields for each contact below. Neglect to complete any or all of the required fields will result in no changes being made to the domain registration record.

Administrative Contact:
Company:
Address:
Address 2:
City:
State:
ZIP Code/Postal Code:
Country:
Phone #:
Email:

Technical Contact:
Company:
Address:
Address 2:
City:
State:
ZIP Code/Postal Code:
Country:
Phone #:
Email:

Billing Contact:
Company:
Address:
Address 2:
City:
State:
ZIP Code/Postal Code:
Country:
Phone #:
Email:

Primary Name Server:
Primary IP Address:
Secondary Name Server:
Secondary IP Address: