<TABLE BORDER="1" WIDTH=550 CELLPADDING="3" CELLSPACING="0">
<TR>
  <TD COLSPAN="2" bgcolor="#93D5BE" align=center>
    <B><FONT face="verdana, arial" size=2>Nexus Information</FONT></B>
  </TD>
</TR>
<TR>
  <TD ALIGN=left bgcolor="#e0e0e0">
    <font face="verdana, arial" size=2><B>Domain Name Application Purpose</B></font>
  </TD>
  <TD>
    <SELECT NAME="app_purpose">
      {{app_purpose_menu}}
    </SELECT>
  </TD>
</TR>
<TR>
  <TD ALIGN=left bgcolor="#e0e0e0">
    <font face="verdana, arial" size=2><B>Nexus Category of Applicant</B></font>
    <FONT SIZE="-1">
      (please choose one)
    </FONT>
  </TD>
  <TD>
    <B>Category 1 - A natural person:</B>
    <BR><INPUT TYPE="radio" NAME="nexus_category" VALUE="C11" {{category_C11}}>Who is a United States citizen
    <BR><INPUT TYPE="radio" NAME="nexus_category" VALUE="C12" {{category_C12}}>Who is a permanent resident of the United States of America or any of its possessions or territories
    <BR><HR WIDTH="100%"><B>Category 2 - U.S. Corporation</B>
    <BR><INPUT TYPE="radio" NAME="nexus_category" VALUE="C21" {{category_C21}}>U.S. organization incorporated within one of the 50 states of a U.S. territory
    <BR><HR WIDTH="100%"><B>Category 3 - Bona Fide U.S. Presence</B>
    <BR><INPUT TYPE="radio" NAME="nexus_category" VALUE="C31" {{category_C31}}>Regularly engages in lawful activities (sales of good or services or other business, commercial or non-commercial, including not-for-profit relations in the United States).
    <BR><INPUT TYPE="radio" NAME="nexus_category" VALUE="C32" {{category_C32}}>Entity has an office or other facility in the U.S.
    <BR><B>Country of Citizenship:</B>&nbsp;&nbsp;
        <SELECT NAME="nexus_validator">
          <OPTION VALUE="">---- Select Country ----
            {{citizen_country_list}}
        </SELECT>
  </TD>
</TR>
<input type=hidden name="old_app_purpose" value="{{old_app_purpose}}">
<input type=hidden name="old_nexus_category" value="{{old_nexus_category}}">
<input type=hidden name="old_nexus_validator" value="{{old_nexus_validator}}">
</TABLE>
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