#############################################
Additional IPv4 Allocation Request Template
#############################################

Document Name: afrinic-ipv4-add-alloc
Date: Jan. 2005
Version: 1.01

# MEMBER INFORMATION:
#
# LIRs org_id and legal organisation name

org_id:
org_name:

# REQUESTOR DETAILS
#
# Please enter the details of the person at your Local
# Internet Registry (LIR) who is submitting this request.

name:
phone:
fax-no:
e-mail:
nic-hdl:

# What prefix size are you requesting now?

prefix_requested:

# Please add any supplementary information that
# you think may facilitate the evaluation of this request below.

Additional_comments:

################ END OF REQUEST ######################