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ORDER FORM

PREFERRED SERVICE

LOCATION

SERVICE

PACKAGE

EXPECTED DATE OF INSTALLATION

PREFERRED TIME

BILLING INFORMATION

TITLE

FIRST NAME

LAST NAME

HOME PHONE

PHONE NUMBER

ALTERNATE PHONE

Email

DATE OF BIRTH

ADDRESS

CITY

PROVINCE

POSTAL CODE

PAYMENT

Credit card

Debit card

Name on card Full name as displayed on card

Credit card number

Expiration

CVV

Current Month Payment

Next Month Payment

Activation Fee

Device Price

Total Price

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