DMCA Designated Agent Service Intake Form Service Provider Legal Name* Full Legal Individual or Business Entity Name If an individual is the service provider (sole-proprietor), please provide the full legal name, OR provide the full legal name of any business entity that is the service provider instead (in the First Name box) as it appears on the organizing documents (i.e. "Acme, LLC"). What you list here will appear on the DMCA records as the name of the service provider. This means the full legal name of an individual sole-proprietor, corporation or LLC name if applicable. We WILL NOT do any independent review of applicable secretary of state databases to determine the actual service provider correct legal entity name-this is your responsibility to confirm before submitting this form. Note, the US Copyright Office will require us to provide the actual full address for your company and not a P.O. Box unless you receive permission to do so. (This address is visible on the DMCA database, but not the service provider phone or email contact info.)Email* Phone*Principal Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Provide the principal business address of the website/app operator. Service providers are required to supply the full physical street address and not a P.O. Box (or virtual address). However, you may petition the Copyright Office for permission to use a P.O. Box (or virtual address). You will be required to take this step separately after registration. Please note, any address information will be reflected on the DMCA database in connection with the service provider. P.O. Box? Yes If the use of a P.O. Box for the ISP business address was already approved by the U.S. Copyright Office and you wish to continue to list this address, check yes below. (this may apply where the ISP had a prior registration using a different DMCA designated agent). Describe the type of online property that will designate a DMCA Agent?* Website (platform, blog, etc.) Mobile App Plugin Other Provide the domain name(s) or full names of your mobile app(s). Please note that for website addresses, the U.S. Copyright Office considers providing the top-level domain (e.g., internetlegalattorney.com) sufficient to comply with Office regulations. It is not necessary to list all subdomains operated by the same service provider.*Provide all alternate names that the public would be likely to use to search for the service provider’s designated agent in the directory, including all names under which the service provider is doing business, website names, website addresses (i.e., URLs, such as "__.com" or "__.org"), software application names, and other commonly used names. Do not include separate legal entities as alternate names. Separate legal entities must be registered separately.If you operate a website, check which general type of website (more then one may apply) Blog, Social Platform or Forum E-commerce Site (Tangible Goods) Membership/Subscription Services Site Information-Only Site or Directory Affiliate/Reseller Site (E-books & Information Products) Affiliate/Reseller Site (Tangible Goods) Advertising or Sales Platform/Forum Site E-commerce Site (E-books & Information Products) E-commerce Site (Software or SaaS) Other How Did You Find Us?*Search EnginePPC AdDirect ReferralSocial MediaDMCA Agent Services Agreement. Your Signature-Type your name below to accept this Engagement Agreement*Shortly after you submit your information, you will be sent a payment link to complete your order. Attorney Philip A. Nicolosi will conduct a preliminary review your website. We may then contact you to gather more details about your website, to the extent necessary.