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User Information Billing Information
User First Name:______________________________ Invoice To:______________________________________ User Last Name:______________________________ Care Of:________________________________________ Address:____________________________________ Address:_________________________________________ ___________________________________________ _______________________________________________ City:_______________________________________ City:_____________________________________________ Province:____________________________________ Province:_________________________________________ Postal Code:_______________ Postal Code:_______________ Telephone:_____________________________________ Business Telephone:______________________________ Personal Credit Information Employer:________________________________________________________ Birthdate:___/___/______. Social Insurance Number:_____________________________________________ Driver's License:____________________________________________________ Major Credit Card:__________________________________________________ Circle One: AMEX VISA M/C Customer's Signature__________________________________________________ _____________________________________________________________________________________ Office Use Only: Make:______________________________ N-Order:______________________________ Model:______________________________ Cell:___________________________________ ESN:_______________________________ Corp:__________________________________ Ser#:_______________________________ MSD:_________________________________ Plan:_______________________________ Term:__________________________________ Phone-$ Cla$ LC$ **PLEASE PRINT AND THEN FAX THIS FORM TO 416-481-6819, YOU WILL BE CONTACTED SHORTLY**
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