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SECURE ONLINE SIGN-UP FORM
Customer Information
Company:
First Name:
Last Name:
Address:
Tel:
Fax:
Email:

Service Information
ADSL
Business Basic
Business Pro
Business Premium
Personal Option 1
Personal Option 2
DIAL-UP
Unlimited
Daytime
Daytime Plus
WEB HOSTING
Basic Host
Semi-Pro Host
Pro Host
WEB PROMOTION
General Promotion
Overture Promotion
Yahoo Promotion
SERVER CO-LOCATION
Package 1
Package 2
Package 3
OTHER
ISDN
E-Commerce

Payment Information
Credit Card
PAP Automatic Bank Withdrawal
Cheque/Money Order
Call Me

Billing Cycle
Monthly 3 Months 6 Months 1 Year

Agreement
I certify that all information provided on this form is true and correct. If this is a credit card purchase, I hereby authorize Hazard Communications Inc. (HCI) to automatically renew my account and bill my credit card for expenses incurred per the membership option selected unless I notify HCI otherwise. If payment is not received within 10 days of notification of decline, I accept that my account will be cancelled. If I terminate my account before my membership expires, a cancellation fee will be applied before refund is provided on a prorated basis to the nearest month. I understand that all my personal information is considered confidential and will not be distributed.

PREFER TO SIGNUP BY PHONE - Simply call our Sales department at 604-803-7355. We are open 9am to 5pm, Mon-Fri.