Customer Information
* = Required Fields
Title :   Mr Mrs Ms
First Name :   * Last Name :   *
Company :  
Address :   * Apt. :  
City :   *
Province :   * Quebec Ontario
Postal Code :   *
Current Email :  
Operating System :  
Preferred language :   English French
    Where and when is best to reach you?
Home Phone :   * Home  From to
Work Phone :   Ext.: Work  From to
Cell. Phone :   Cell.    From to

Required Information
Are you a current Contact, Synapse, or Aei member? Yes No
If Yes, please provide your current Username (ex: johndoe@aei.ca) :  
If No, please choose a Username (15 char. max) :  
2nd Username choice, if 1st taken :  
Please choose a password (min 4 char.) :  
Do you already have the High Speed service with Bell Sympatico? Yes No
If Yes, provide your
   Cancelation Number :  
   Cancelation Date :  

Order Information
Please note:
  - Your service will be active in approximately 5 working days after the order is accepted.
    - The monthly payment for the High Speed Service is by credit card only.
    - Activation fee will be charged on the first service invoice:
   ADSL=$25.00;  FTTN=$100.00;  DryLoop ADSL=50.00$;  DryLoop FTTN=125.00$
  Phone number for the HighSpeed Service: * - -
 
High Speed service requested:
*

Is the phone service with Bell Canada? Yes No
If No, with whom (ex: Sprint ) :  
Is there a password on the phone account? Yes No
If Yes, specify # :  
Is the phone line presently active? Yes No
If No, when will it be :  
Would you like to specify a future installation date ? Yes No
If Yes, specify a date (minimum date 24-04-2014) :  
Name on Bell phone bill First Name : Last Name :
*Please verify your phone bill, an incorrect name will cause your order to be rejected.
Service Address, if different from the billing address in the section - Customer Information
Address :   Apt. :  
City :   Postal Code :  
Province :   Quebec Ontario
I already own an ADSL modem Type:
RENT - ADSL2+ modem Camatel Netvito 5300 @ $10.00 + tx
RENT - Wireless VDSL2+ modem Sagemcomm F@ST2864 @ $10.00 + tx
PURCHASE - ADSL2+ modem Camatel Netvito 5300 @ $75.00 + tx
PURCHASE - Wireless VDSL2+ modem Sagemcomm F@ST2864 @ $150.00 + tx
PURCHASE - SmartRG 505n VDSL Wireless modem/router @ $120.00 + tx
Purchase - ADSL Telephone filters @ $7.50 each + tx
        (Normally, one filter per connected telephone is needed in the residence.)
   Qty:
  Modem Pickup:   405 de la Concorde downtown Montreal  
Shipping Address
  Billing (In the Customer Information section)
  OR         Service (Address on the phone bill)
  Delivery:   Modem w/Filters - $20.00       Other (To be provided in the Comments section)
       Filters only - $4.95        

Payment Information
  I would like to be contacted by phone for my credit card information
  - OR -
  Credit Card: Card Number:  Expiration: Month: Year:
  Name on Card:
  Card Type:       CVV Number:
(last 3 digits located on the back of card or 4 digits on the front for Amex cards)

Other Information
  How did you hear about us?
 
Questions or Comments:
 

I attest that I have read and I am in agreement with the terms and conditions of the service agreement.