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Name

Email Address

Subject

Department

Priority

Message

Attachments

Allowed File Extensions: .jpg, .gif, .jpeg, .png, .doc, .txt, .ott, .ott, .xls, .csv, .rtf, .pdf, .docx, .img

Unit or Suite No. (If Applicable)

Street Address To Be Checked For Serviceability - Then Please Answer Other Questions

(Please inclue any Unit, Suite or Apartment Number.)

City or Town (or Equivalent)

Province

Postal Code

Is there a Cable TV line running to your home (active or not)?

Do not leave blank.

Do you currenty have high speed internet over the cable TV line?

Do not leave blank.

Please enter name of current Cable Internet provider (if applicable)

Do you currently have an active telephone number & landline at your home?

Do not leave blank.

Do you currently have internet over the phone line (DSL or FTTN or Fibe)?

Do not leave blank.

If Yes - Please Enter Land Line Area Code & Phone Number

(This may help us better locate your address. We will not call you.)

Will The Internet Be For Home or Business Use?

Do not leave blank.