Order Cable-Internet

**Your Contact Information:**
First Name:
Last Name:
E-mail Address:
Your Phone Number:	Format: 123-456-7890

**Your Service Address:**
Street Number:
Street Name:
Suite/Unit/Apt:
City:
Province:	Ontario
Postal Code:

**Choose Your Service Plan:**
Cable-R6 Cable-R30 Cable-R75 Cable-R300 Add StaticDNSIP

Equipment Options:
Supply Your Own Equipment
Buy Modem/Router/WiFi Unit

Installation Options:
New Installation
Transfer Service

**Credit Card Information:**
Name on Credit Card:
Credit Card Number:
Credit Card Expiry Date:
Credit Card CCV:

**Special Instructions or Additional Information:**
Enter text here…

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