Internet Services

Pre-Authorized Payment Plan You can pay for your Internet access account through your financial institution using the Pre-Authorized Payment Plan. Please complete the following form and send it to our office by mail accompanied by a cheque for the first month's payment and a void cheque to activate the Pre-Authorized Payment Plan. If you have any questions about this payment plan,  email salesrep@platinum1.com. I/we, the undersigned, hereby authorize Platinum Connections Ltd. to withdraw the amount due plus all applicable taxes from my/our financial institution on the monthly anniversary of my/our account activation. First Name ___________________ Last Name _____________________________________ Address ________________________________________ City_________________________ Province____________ Postal Code_________________ Home Phone _______________ Work Phone _______________ Fax _______________ Date of birth: ___________ Driver's license# __________________________ Province ____ (Driver's license is for proof of age, all information is confidential.) I am at least 18 years old _____ I am not yet 18 years old _____ (initial one) If you are under the age of 18, your application will not be processed without an accompanying completed parental release form signed by your legal guardian. BY SIGNING THIS FORM, I ATTEST THAT ALL THE INFORMATION PROVIDED IS TRUE AND ACCURATE. I HAVE READ THE TERMS AND CONDITIONS OF PLATINUM CONNECTIONS LTD AND I AGREE TO ALL TERMS AND CONDITIONS SET FORTH. SIGNATURE:______________________________________ DATE:__________________________ SIGNATURE:______________________________________ DATE:__________________________ (If joint account all signatures are required)