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
If you have any questions about this payment plan, email firstname.lastname@example.org.
First Name ___________________ Last Name _____________________________________
City_________________________ Province____________ Postal Code_________________
Home Phone _______________ Work Phone _______________ Fax _______________
Date of birth: ___________ Driver's license# __________________________
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.
(If joint account all signatures are required)
Terms and Conditions
Parental Release Form