Dialup Internet Connection Signup Form
Contact Information
First Name:
Last Name:
Address:
City:
Province: Postal Code:
Phone:
User Information
Preferred Username:
Note:
Your username will become the first part of your email address, ie: jsmith -> jsmith@ecn.ab.ca
Password:
Term:
12 Months ($99.00+GST)
1 Month ($9.25 + GST)
Billing Information
Please Bill my Credit Card :
Credit card #
Expiry: (mm/yy)
My cheque is enclosed for the amount of $103.95 ($99.00 + GST) for 12 months service
My cheque is enclosed for the amount of $9.71 ($9.25 + GST) for 1 month service