Dialup Internet Connection Signup Form

Contact Information

First Name:

Last Name:

Address:

City:

Province: Postal Code:

Phone:

User Information

Preferred Username:
Note: Your username will become the first part of your email address, ie: jsmith -> jsmith@ecn.ab.ca

Password:

Term:
12 Months ($99.00+GST)
1 Month ($9.25 + GST)

Billing Information

Please Bill my Credit Card :
Credit card # Expiry: (mm/yy)
My cheque is enclosed for the amount of $103.95 ($99.00 + GST) for 12 months service
My cheque is enclosed for the amount of $9.71 ($9.25 + GST) for 1 month service

  Signed: _______________________________________ Date: ____________

Please Fill out the form below completely. Once completed, print and fax it to us at (780) 413-1869 or Mail it to us at:

Tera-Byte Dot Com Inc.
Terminal Level
10004-104 Avenue
Edmonton, Alberta
T5J 0K1

Please allow up to 24 hours to set up faxed orders. Orders sent in via postal mail will be set up within 24 hours of usreceiving them.
To check the status of your order, please call us at (780) 413-1868