Tracking number - V2000-2512

Client Name _______________________________________________________________

Username/Login ______________________  Date _______-_______-_______(D-M-Y)

Address: __________________________________________________________________

City: ___________________________     Prov ________     PC ___________

Plan ____________________________     Tracking # from E-Bill  _______________

Check here if you are changing plans:  [ ]         Mail me a copy of the receipt Yes[ ] No[ ]

Name as it appears on the card ___________________________________________

VISA / MASTER card # ________    _________    _________    _________

EXPIRY date ______  /  ______       (Numbers Only   ie: 02 / 02)

Phone Number ____________________________
 

                                         Amount    $________.___

                                         Overhours $________.___

                        GST# R898601851  GST(7%)   $________.___

                                         PST(8%)   $________.___

                                         Total     $________.___

Cardholder's SIGNATURE:  ________________________

Notes   ________________________________________________________

________________________________________________________________

BBS 42 P.O. Box 458 Guelph, ON N1H 6K9 824-6060
For Office use only.

Authorization ____________________   Due  ______________