Multipage Form

Cable-Internet Service Plan and Options:

Account Number,(if known):

Cable Line Speed:
   Bronze(15/2)
   Silver(40/10)
   Gold(60/10)

Equipment Options:
   Buy Cable Modem
   Lease,(Rent to Own)
   Customer already has their own Cable Modem as follows:
           Modem Make/Model:
           Modem Serial Number:
           Modem Mac Address:

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VoIP Telephone:

Add VoIP Telephone for $10/mth?
Yes
No

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Activation Appointment:

Type of Installation?
New Service
Transfer from Another ISP

Requested Date of Installation:
- Please allow at least five(5) business days from the time you place the order.
- Installations are done Monday to Friday, (ie. NO weekend installs).
First Choice,(DD/MM/YY):

Second Choice,(DD/MM/YY):

Third Choice,(DD/MM/YY):

We will let you know the day of the installation once a technician is assigned,(which is "usually" within 2 business days of placing this order).
Contact Phone Number:

This number must be answered by a "live" person on the day of installation as the installer will "probably" call it before showing up, if he/she is unable to reach anyone, the installation may be cancelled and it will have to be re-booked.

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User Information:

First Name: Last Name:

Street Number: Street Name:

Unit:

City: Prov:

Postal Code:

E-Mail Address:

Phone Number:

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Credit Card Information:

Name on Credit Card:

Credit Card Number:

Credit Card Expiry Date:

Credit Card CCV:

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Any Special Instructions or Additional Information:

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