Please complete all sections of the form. If you have any problems in completing the form please email applyhelp@nixp.net . If you prefer to send the application form by email, copy and paste the form to your email program and email it to apply@nixp.net. A PDF version can also be downloaded, filled inline and sent as an email attachment. It can also be printed as filled inline and submitted by post/hand.

[1. Details of Organisation] Name of Organisation .................: Registration No ......................: Registered Address ...................: Postal Address (if different) ........: Telephone ............................: Fax ..................................: [2. Contacts] /Administrative Contact/ Person-Name ..........................: Address ..............................: Phone No .............................: Fax No ...............................: Email ................................: /Technical Contact/ Person-Name ..........................: Address ..............................: Phone No .............................: Fax No ...............................: Email ................................: /Billing Contact/ Person-Name ..........................: Address ..............................: Phone No .............................: Fax No ...............................: Email ................................: [3. Connection Information] AS number(s) to use for peering ......: Required Port Capacity ...............: Required Number of Ports .............: NIX location to connect to ...........: [4. Operational Contact] 24x7 NOC Phone No ....................: NOC Email ............................: Email for NIX Discussion List ........: [5. MoU] Have you read the MoU? ...............: <-------------------------------------> [6. Optional Questions ] What type of permanent connection to the Internet do you have? (e.g. Wireless, VSAT, SAT3): Bandwidth of the Connection: Please list your Upstream Provider(s), list their names and AS Number: Please provide a brief description of your organisation: Organisation URL: 7. Sales Contact Person-Name: Phone No.: Email: