Your eWebExtra webpage will be retired. If you would like to keep the web address associated with your retiring webpage, domain names may be retained by completing this form before the retirement date.
After the domain is transferred, your practice will be responsible for managing the domain and any related services.
If you do not wish to transfer and own the domain, no further action is needed.
All fields are required unless noted.
If you do not wish to transfer and own the domain associated with your eWebExtra webpage, no further action is needed.
Electronic Signature Agreement
By entering your full name below, you are agreeing that (a) your electronic signature will be enforceable as and to the full extent of a hand-written signature as an original for enforcement/enforceability of this documented request, whether in court (state or federal), arbitration or otherwise, (b) you will not raise any defenses or invoke regulatory or statutory claims attempting to invalidate the enforceability of this documented request, (c) you are authorized by the contracting party to submit this request, and (d) all information provided with this request is true and accurate.
