APPLICANT FORM

Mobile service subscription form

Customer information

Suffix *

This field is required !

First Name *

This field is required !

Last Name *

This field is required !

Address *

This field is required !

City *

This field is required !

Province *

This field is required !

Postal Code *

This field is required !

Home Telephone

Cell Phone

Email *

This field is required !

Credit Card Number *

This field is required !

Expiration *

This field is required !

Subscription

Plan *

This field is required !

New PhoneNumber

Indication *

This field is required !

Transfer existing number

This field is required !

Phone number *

This field is required !

Supplier Name *

This field is required !

Account Number *

This field is required !

Subscription condition

MONTHLY PACKAGES WITHOUT CONTRACT
FEES FOR 911 SERVICE NOT INCLUDED
SALES TAXES NOT INCLUDED
$ 50 / ADDITIONAL Gb
PRE-AUTHORIZED PAYMENT ONLY
NO ROAMING OPTION NO OPTION
OTHER LONG DISTANCE CALL NOT INCLUDED
$ 35 RECONNECTION FEE FOR NON-PAYMENT
PAYMENTS ARE DUE ON THE 20TH DAY OF EACH MONTH
1 MONTH DEPOSIT + PRO RATE OF THE MONTH UPON ACTIVATION

I have read and accept all the conditions of membership

This field is required !

Agent:

Thank You for your subscription.

In the nest comings days, you will receive your new Sim Card with instruction to complete the transfert of your phone number or your new Sim card with new phone number.

You will also receive instruction for assessing your invoice online.

PAGU - Partnering for success!

Mobile service subscription form

Customer information

Subscription