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Domain Name Registration Form

(Please provide 5 options for required domain name)
 
Your Name
Postal Address
E-mail
Telephone No
Fax No
Domain Name to be registered (Option 1)
(Option 2)
(Option 3)
(Option 4)
(Option 5)
I also need more information on the following  Web Space  Design & Development
I agree to pay Rs. 5000/- (or USD 130.00) for search, confirmation and registration with InterNIC, valid for two years by DD in favour of "Thomson Jacob" payable at Nagpur.