TEL: 613-638-7202

FAX: 613-638-7039

Name:_______________________________

Address:_____________________________

City:_____________Postal Code:_________

Phone#:___________Work#:_____________

Set Up Date:___________________________

Which package do you wish to have?

_______________________________________

Your Login:
Your login and password cannot be the same.

First Choice: __/__/__/__/__/__/__/__/

Second Choice: __/__/__/__/__/__/__/__/

Your Password:

Your Choice: __/__/__/__/__/__/__/__/

Computer: 486[ ] Pentium[ ] MacIntosh[ ]
OS:Win 3.1[ ] Win 95[ ] Win 98[ ] Mac[ ]
Modem Speed: 14.4[ ] 28.8[ ] 33.6[ ] 56.6[ ]
 Payment Options:
NRTC Communications offers two payment options; credit card payment or through Pre-Authorized Payment. The monthly charges will appear on your credit card or bank statement.

A.

I authorize NRTC Communications to process my payment as follows:

VISA[ ]    Mastercard[ ]

Cardholder name:_______________

Account No:
_______-_______-_______-_______

Expiry Date:_____/_____

Signature:___________________________

B.

I authorize NRTC Communications to withdraw the amount due on my monthly bill from my financial institution, on a monthly basis, for payment of my Internet account.

Signature:________________________

Acct. No:_____________________
FOR OFFICE USE ONLY: Account Created ( )  Customer Called ( )  Work Order ( )
I declare that I am eighteen years of age I request North Renfrew Telephone Company Limited to furnish, subject at all times to lawful rates and regulations as filed with the CRTC, and as on file at the Company's business office, Internet access as detailed herein, and as may be ordered from time to time, either orally or in writing, and agree to pay all charges in accordance with said rates and regulations. I authorize and consent to the receipt and provision of account and credit information from and to credit grantors, and credit bureaus. Provision of Internet access or the necessity of a security deposit or alternative remains the discretion of the telephone company. I will indemnify North Renfrew Telephone Company Limited for any loss suffered by reason of improper use of the Internet connection and will compensate anyone harmed by any abusive use of the Internet connection. I agree that once connected, I will abide by all Canadian and International laws pertaining to the Internet and ist use. I will advocate myself regarding privacy, obscenity, and commercial information. In consideration for the privilege of using North Renfrew Telephone Company's Internet service and in combination for having access to the information contained on it, I hereby release North Renfrew Telephone Company Limited from any and all claims of any nature arising from the use, or inability to use, the Internet connection. I will not divulge my account number. I authorize NRTC Communications to give my password to my representative

Signature:_________________________________________ Date:____/____/____