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New Customer Application
Simply fill out the following information to get started!
Your Information
First Name
*
Middle Initial
*
Last Name
*
City/ Town or First Nations Name
*
Previous Provider's Name
*
Your Previous phone #
*
Best Time To Contact Me
Birth Date
*
Email
*
Your Home Address Information
St. Address/House # or Legal Land discription
*
City/ Town or First Nations Name
*
Province
*
Postal Code
*
First Nations
*
Yes
No
Your Mailing Address Information
St. Address or Box #
*
City/ Town or First Nations Name
*
Province
*
Postal Code
*
First Nations
*
Yes
No
Additional Information
Neighbor's Name
Neighbour's 10 Digit Phone #
Day Contact Name 1
*
Contact 10 Digit Phone #
*
Day Contact Name 2
*
Contact 10 Digit Phone #
*
Jacks required
*
yes
no
Phone Line Residence Required
*
Yes
No
How Did You Hear About Us?
*
Referral
Radio
Poster
Bus Card
Web
Friend
Newspaper
Print Ad
Driving Instructions
*
ASAP or Date To Start Service?
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2022
2023
2024
2025
2026
Please allow 3 to 10 business days in most provinces.
What features do you require with your land line?
Call Display
Call Waiting
Call Answer
Call FWD
Voice Mail
Call Screen
Long Distance
Internet
3 Way Call
Call Return
Non Pub #
Transfer name of company