Get Connected. Stay Connected.

Residential Service Agreement #280 550 71 Avenue SE Calgary, Alberta T2H 0S6 Toll Free (866) 301.4590 | Fax (866) 876.5351

internet, digital phone and more...

Email sales@platinum.ca

CUSTOMER INFORMATION
FULL NAME: PRIMARY PHONE:

ADDRESS: (Where service is to be installed)

SECOND PHONE:

COMPANY NAME: (If selecting small business plan)

BUSINESS PHONE:

CITY / TOWN:

POSTAL CODE:

LEGAL LAND DESCRIPTION (Quarter, Section, Range, Meridian) OR GPS COORDINATES

EMAIL ADDRESS: (Required for e-billing) USE MY PLATINUM EMAIL ADDRESS

DIGITAL PHONE INFORMATION

If available/applicable WILL YOU BE USING A ROUTER? YES NO

RURAL 911 ADDRESS: (Where to locate you in an emergency) e.x. 999 Range Road, Red Deer T2Y-1K8

WHAT WOULD YOU LIKE TO SEE ON YOUR CALL DISPLAY:

SELECT YOUR PLAN

A B C D

X
Basic Residential Internet - 100 GB Promo Residential Internet with Digital Phone Bundle Residential Internet with Unlimited LD Digital Phone Bundle Standalone plan with available no contract option $12.95 webLITE

MONTHLY NO CONTRACT

MONTHLY 2 YEAR TERM

Platinum PRO Platinum PRO PLUS Platinum PRO ULTIMATE DIGITAL PHONE

$59.95 $79.95 $89.95 $39.95 $22.95 webPRO

$49.95 $69.95 $79.95 $29.95 $42.95 webMAX

WEB HOSTING [3 available options to suit residential requirements]

BUILD YOUR SERVICE PACKAGE Service Plan (A,B,C, or D) Select Your Web Hosting Plan (If Applicable) INSTALL FEE OPTIONS (Pick One That Suits You)
(I want to save $100.00 on my install!) (I want my install for free!) (I want to get a new netbook with my install!)

Residential Service Agreement

ALL OF THE TERMS AND CONDITIONS ON WWW.PLATINUM.CA AND HEREIN FORM THE ENTIRE AGREEMENT BETWEEN PLATINUM COMMUNICATIONS AND THE CUSTOMER.

A B

No Contract 2 Year Contract 2 Year Contract Sub Total G.S.T. 5% TOTAL

$299.95 $199.95 $299.95 $299.95

I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS ON AND HEREIN WISH TO CONTRACT WITH PLATINUM COMMUNICATIONS TO PROVIDE SERVICE. VOIP PHONE EMERGENCY 9-1-1 FEATURES DIFFER FROM TRADITIONAL 9-1-1 SERVICES. VISIT www.platinum.ca FOR MORE INFORMATION.

(Service Plan+Hosting+Install Fee)

SIGNATURE DATE PAGE 1/2

G e t C o n n e c t e d . S t a y C o Commercial . nnected Residential

Residential Service Agreement #15 6320 - 11 Street SE Calgary, Alberta T2H 2L7 Toll Free (866) 301.4590 | Fax (866) 876.5351

YOUR LOCAL
internet, digital phone and more...

Email sales@platinum.ca

PAYMENT INFORMATION, SELECT ONE: CREDIT CARD OR PRE-AUTHORIZED DEBIT (PAD) CREDIT CARD
CREDIT CARD NUMBER (I hereby authorize Platinum Communications Corp. to automatically bill the card listed above for any installation, activation, service call, termination, and monthly recurring charges). EXPIRY CREDIT CARD TYPE

SIGNATURE
CARD HOLDER NAME - As shown on the credit card

DATE

SEND MY INVOICE VIA EMAIL

SEND MY INVOICE VIA CANADA POST ($2.50/PER MAIL OUT)

Pre-Authorized Payment Schedule To: Platinum Communications Corporation (the Company)

PRE-AUTHORIZED DEBIT (PAD) - (ADDITIONAL LEGAL ON PAGE 5)

CUSTOMER / BUSINESS NAME

VOID
I/We [the above named Customer(s)] authorize the Company to debit my/our account at the Bank as given, in the amount of: (see schedule A: Total Fee Due Monthly page 5) $______________ on the First (1st), or the Fifteenth (15th) (circle one) day of each month payable to the Company in respect of: Internet access fees and taxes as applicable. Each payment shall be the same as if I/we had personally issued a cheque authorizing the Bank to pay the Company as indicated and to debit the I/We will provide 45 days notice in writing to the Company if I/we close this account. If I/we are unable to provide the Company with 45 days written I/We understand that the Bank is not responsible to verify whether these payments are properly debited to my/our account. This authorization may be cancelled at any time upon written notice by me/us to the Company. I/We understand that if I/we cancel this authorization, it does not mean that my/our contract obligations to the Company are ended. Any delivery of this authorization to the Company constitutes delivery by me/us to the Bank. I/We am/are the only authorized signature(s) on the above given.

SIGNATURE

SIGNATURE

* REMEMBER * ATTACH VOID CHEQUE TO THIS PAGE

DATE

DATE

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