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Northern Ontario Wires Inc.
Town of Cochrane
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Cochrane Telecom Services
Broadband ADSL Internet Application
|
Section 1 - Service Address |
| Name: _____________________________ |
Service Address:
_____________________________ |
| Mailing Address:
____________________ |
City: _____________ Postal
Code: ______________ |
| Telephone Number: __________________ |
Daytime Contact Number:
_____________________ |
| Telephone Number to bill ADSL to (if
different from above): __________________________________ |
|
Section 2 - Check for Existing Internet
Service |
| Do you currently have Dial-Up Internet Service with
CTS for your computer? |
q Yes
q No
|
| If Yes, proceed to Section 3 - Existing
Dial-Up Customer |
|
| If No, proceed to Section 4 - ADSL
Service Sign-Up |
|
|
Section 3 - Existing Dial-Up Customer |
| Do you wish to cancel your
CTS Dial-Up account upon receiving ADSL service with us? |
q Yes
q No |
| Please note:
Ontera bills for Dial-Up accounts for the whole month, they do not make
adjustments if you cancel before the end of the month. |
| Date to have Dial-Up Service
Terminated (if different than ADSL installation Date):______________ |
|
| Do you use a second
residential/business telephone number for your Dial-Up Internet? |
q Yes
q No |
| If Yes, would you like to have this line
disconnected when your ADSL is installed? |
q Yes
q No |
| What is the phone number you
would like disconnected? __________________________ |
| Please
proceed to Section 4 - ADSL Service Sign-Up |
|
Section 4 - ADSL Service Sign-Up |
| Which service are you subscribing to? |
|
| q |
WarpFactor 1; Up to
2 Mbbit/s
download speed $39.95* per month + $60.00*
installation charge (*one time fee). |
| q |
WarpFactor
2; Up to 3 Mbit/s
download speed $49.95* per month + $60.00*
installation charge (*one time fee). |
| q |
WarpFactor
3; Up to 5 Mbit/s
download speed $69.95* per month + $60.00*
installation charge (*one time fee). |
| Your preferred email address: |
|
| First Choice: _____________________@puc.net |
Second Choice:
__________________@puc.net |
| Is there a telephone line/extension at
your computer location? |
q Yes
q No |
| *A separate charge
will apply if a jack installation is required. |
| Do you require additional Dial-Up access
for roaming? (access from other locations) |
q Yes
q No |
| If yes,
please fill out the Dial-Up application form and choose the package your
require. |
|
Section 5 - Agreement |
|
WarpFactor Service will be billed to
the telephone number you list. You will see the charge on your next
telephone bill. WarpFactor is billed one month in advance of service
being provided. It is possible that you will be billed for two months on
your next bill. You may cancel your service at any time. Cancellation
and charges may become effective one day prior to your next billing. The
ADSL modem and splitter remain the property of Cochrane Telecom
Services. Upon the termination of service, the equipment must be
returned to CTS immediately. |
|
A deposit of $75 may be required and
is refundable after one year of perfect payment history. |
| Signature:___________________________________ |
Date:_____________________ |
|
