• Addresses are allocated only following a correctly completed application,
• Entered data should be actual and reflect real address needs,
• Please read cerefully instructions how to complete this form

NOTE:
Assignment is valid as long as the original criteria on which the assignment was based are still valid. We have the right to reassign the address space to another user upon termination of this agreement or an agreed period thereafter.

If you have any questions concerning IP address allocation, please contact: registry@nask.pl.

Contact e-mail address*:
A short description of the applicant organization*:

The Applicant
First and last name*:
Organization*:
Phone* (+48 10xx 22 1234567 ext. 110):
Fax:
E-mail*:

The Address User Leave empty, if the data is the same as the applicant’s data.
First and last name:
Organization:
Telephone (+48 10xx 22 1234567 ext. 110):
Fax:
E-mail:

Currently Used Addresses In the table below, please enter the subnets you are currently using.
Subnet address	Mask	Description

Returnet addresses (optional) In the table below, please enter the subnets you are returning.
Subnet address	Mask	Description

Application Assignments are for a period of up to 6 months.
Subnet size (/nn)	Address space to use:			Purpose
	Immediate Requirement	Intermediate Requirement.	Entire Period

Address space available?:
Your Internet Service Provider*:
Have you considered using private classes?:
Have your previous applications been rejected? Why?
Do you need Point-to-Point subnet (/30)?:	NO YES

Equipment at End User site:
Equipment name	Manufacturer name	Model	Other data

Enter Data to the RIPE Database: The data below will be entered to the public internet address database. The form should not contain encoded Polish extended characters.
Accept conditions included in the form*:	NO YES
Netname: (only letters and digits)*:
Description*:
Remarks:
Administrative Contact Fields should consist of proper and actual contact data.
First and *:
Address (Full postal address)*:
Address (Full postal address)*:
Phone*:
Fax:
E-mail*:
Technical Contact Leave empty, if the data is the same as the administrative contact data. Fields should consist of proper and actual contact data.
Imię i nazwisko:
Address (Full postal address):
Address (Full postal address):
Phone:
Fax:
E-mail:

Notes:

|

return to IP address allocation