To Request an authorization letter, as required by the U.S. Government Services Administration, complete the form below. Project Name * Request Date Request Date Year Year20192020202120222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Request Completion Date Expedite Requested Completion Date Expedite Requested Completion Date Yes No Reason or purpose for NY.GOV Domain * Please type here a basic description of the reason or purpose for the domain(s) Organization Administrative Contact Name * Agency name * Telephone Number * Email Address * Address Line 1 * Address Line 2 City * State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code * Domain Details Domain * NY.GOV Server Hostname Domain IP Domain Application Details Details Details Hosted Delegation Domain Approval Only (DNS should be submitted by CIO/OFT IATS) Type * - Select -Name ServerACNameTXTMX Host/Name * IP/Record Data * Priority * Contact Info IT Contact Name * Alt. IT Contact Name IT Contact Telephone * Alt. IT Contact Telephone IT Contact E-mail * Alt. IT Contact E-mail IT Contact Address Line 1 * IT Contact Address Line 2 Other Notes and Comments OFT Customer Relations P.O. Box 2062 Albany, NY 12220-0063 Email: [email protected] Phone: 866-789-4638 or 518-402-2537 Fax: 518-474-1116 *Note: The administrative point of contact must be a government employee and must be the same as the administrative contact listed for this domain on http://www.dotgov.gov/. OFT Customer RelationsP.O. Box 2062Albany, NY 12220-0063Email: [email protected]Phone: 866-789-4638 or 518-402-2537Fax: 518-474-1116*Note: The administrative point of contact must be a government employee and must be the same as the administrative contact listed for this domain on http://www.dotgov.gov/.