Parental Release Form

If you are under the age of 18, and wish to setup an account with Platinum Connections Ltd., you must have a parent or guardian complete and remit this form with your application.

Minors Name:____________________________________________________________

Parent or Guardian 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 HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS FOR INTERNET ACCESS WITH PLATINUM CONNECTIONS LTD.. I AM THE PARENT OR GUARDIAN OF THE MINOR NAMED ON THE ACCOMPANYING APPLICATION FORM AND I CONSENT TO THE APPLICANT HAVING AN ACCOUNT. I UNDERSTAND THE TERMS AND CONDITIONS OF THE SERVICE, AND I AGREE THAT PLATINUM CONNECTIONS LTD HAS NO RESPONSIBILITY TO CENSOR OR OTHERWISE REGULATE THE APPLICANT'S ACCESS TO THE INTERNET. I ALSO AGREE TO BE FINANCIALLY RESPONSIBLE FOR THE SERVICES USED BY THE MINOR NAMED ABOVE.

Parent/Guardian's Signature: ______________________ Today's Date: ______________

If you have any questions, or would like a subscription form faxed or mailed to you, please contact salesrep@platinum1.com.

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