GOV.PH Form No.
R001
Revised 2022
.GOV.PH DOMAIN APPLICATION FORM
(Note: Please read the attached instructions before filling out this form)
COMPLETE NAME OF
ORGANIZATION
COMPLETE ADDRESS OF
ORGANIZATION
REGION
TELEPHONE NUMBER / MOBILE
NUMBER
FAX NUMBER
REQUESTED .GOV.PH DOMAIN
NAME
PURPOSE OF REQUEST
(If your request is an inter-agency initiative
or project, please include the purpose of the
initiative/project. You can use separate paper
if the space provided is not enough.)
NAME SERVER INFORMATION
HOST NAME OF PRIMARY NAME SERVER IP ADDRESS OF PRIMARY NAME SERVER
HOST NAME OF SECONDARY NAME SERVER IP ADDRESS OF SECONDARY NAME SERVER
HOST NAME OF OTHER NAME SERVER IP ADDRESS OF OTHER NAME SERVER
(if applicable)
1. 1.
2. 2.
3. 3.
AUTHORIZED CONTACT PERSON/S
MAIN CONTACT PERSON
NAME: POSITION:
EMAIL ADDRESS: MOBILE NUMBER:
ALTERNATE CONTACT PERSON
NAME: POSITION:
EMAIL ADDRESS: MOBILE NUMBER:
I hereby certify that the information provided in this form is true and correct.
PRINTED NAME AND SIGNATURE
HEAD OF ORGANIZATION
DATE
NOTE: Please send the accomplished form at [email protected]. For inquiries, you may call us at 8-920-0101 ext 6113. Please wait for
an email notification from the .gov.ph Domain Registrar regarding your application. The notice will be emailed to the authorized contact
person/s you indicated in this form.
INSTRUCTIONS IN FILLING OUT .GOV.PH DOMAIN APPLICATION FORM
1. All fields in the form must be filled out. If not applicable, write N/A.
2. Entries in the form may be filled out through handwriting or computer. If
handwritten, please write legibly.
3. To know if you are qualified for a .gov.ph domain sub-delegation, please read
the Philippine Government Internet Domain Name Policy
(https://dns.gov.ph/asti-policy/)
4. Indicate the COMPLETE name of your organization. DO NOT ABBREVIATE (e.g.
Department of Information and Communications Technology).
5. Indicate the COMPLETE address of your agency (e.g. C.P Garcia Ave., Diliman,
Quezon City).
6. Indicate the requested .gov.ph domain name of your agency. The .gov.ph
domain name should NOT contain special characters (e.g. dict.gov.ph).
7. If you are applying for DNS Hosting Service of DICT, please indicate the
following in the name server information fields. No need to indicate the IP
Addresses of the name servers.
* Primary name server: murphy.gov.ph
* Secondary name server: mike.gov.ph
* Other NS: elmo.gov.ph
addresses. A minimum of two (2) name servers are needed for a domain.
8. There should be two (2) authorized contact persons and should be an employee
of your agency. Authorized contact person from a third party is NOT allowed.
Each contact person should have different phone numbers and email addresses.
9. Tick the box e information provided above is true and
10. The Agency Head or MIS head must affix his/her signature over printed name and
indicate the date when the form was signed. For Local Government Units, forms
should be primarily signed by the Municipal Mayor/Provincial Governor, if not
accommodated the Municipal Administrator/Provincial Administrator, or MIS Head
should sign.
11. Submit the scanned copy (in PDF format) together with the letter of request to
[email protected]
GOV.PH Form No. R001
Revised 2022
.GOV.PH DOMAIN APPLICATION FORM
(Note: Please read the attached instructions before filling out this form)
COMPLETE NAME OF Municipality of Alcantara Cebu
ORGANIZATION
COMPLETE ADDRESS OF
Poblacion Alcantara Cebu
ORGANIZATION
REGION VII
TELEPHONE NUMBER / MOBILE (032) 425-5331/ 09429339617
NUMBER
FAX NUMBER N/A
REQUESTED .GOV.PH DOMAIN alcantaracebu.gov.ph
NAME
PURPOSE OF REQUEST
The Municipality of Alcantara Cebu is requesting for a domain name for the
(If your request is an inter-agency initiative
purpose of creating a website which will be used to disseminate
or project, please include the purpose of the
information to the public and transparency.
initiative/project. You can use separate paper
if the space provided is not enough.)
NAME SERVER INFORMATION
HOST NAME OF PRIMARY NAME SERVER IP ADDRESS OF PRIMARY NAME SERVER
murphy.gov.ph 202.90.154.181
HOST NAME OF SECONDARY NAME SERVER IP ADDRESS OF SECONDARY NAME SERVER
mike.gov.ph
202.90.158.241
HOST NAME OF OTHER NAME SERVER IP ADDRESS OF OTHER NAME SERVER
(if applicable)
1. elmo.gov.ph 1. 175.41.160.78
2. 2.
3. 3.
AUTHORIZED CONTACT PERSON/S
MAIN CONTACT PERSON
NAME: POSITION:
Mark Anthony T. Indino LDRRM I / IT
EMAIL ADDRESS: MOBILE NUMBER:
[email protected] 09429339617
ALTERNATE CONTACT PERSON
NAME: POSITION:
Gregorio Salvador Computer Maintenance Technologist II
EMAIL ADDRESS: MOBILE NUMBER:
[email protected] 09174309617
I hereby certify that the information provided in this form is true and correct.
(Please refer to the instructions page for authorized signatories)
PRINTED NAME AND SIGNATURE
HEAD OF ORGANIZATION
01/01/2022
DATE
NOTE: Please send the accomplished form at [email protected]. For inquiries, you may call us at 8-920-0101 ext 6113. Please wait for
an email notification from the .gov.ph Domain Registrar regarding your application. The notice will be emailed to the authorized contact
person/s you indicated in this form.
