Québec Order Form

1

Primary Information* This field is required.

Please enter your email

Telephone # (Mobile)

2

Name* This field is required.

First Name

Last Name

3

Address

Street Address

City

Province

Postal

Country

4

My Products

My Bag

0

Activation Fee - New Connection
$49.95CAD+
Back
Activation Fee - Transfer
$CAD+
Back
Cable Internet Plans (Videotron Areas)
$CAD+
Back
$34.95 / Cable 5 Lite
$34.95 / Cable 5 Lite
$39.95 / Cable 5 Unlimited
$48.95 / Cable 15 Unlimited
$62.95 / Cable 30 Unlimited
$74.95 / Cable 100 Unlimited
Cable Plans
Subtotal: $0.00CAD
DSL Internet Options
$CAD+
Back
$40.95 / DSL 6 Lite
$40.95 / DSL 6 Lite
$45.95 / DSL 6 Unlimited
$59.95 / DSL 25 Unlimited
DSL Plans
Subtotal: $0.00CAD
Cable Modem - I'd like to purchase a modem+$10 one-time shipping applied
$139.95CAD+
Back
Cable Modem - I'd like to rent-to-own a modem12 months +$10 one-time shipping applied
$11.66CAD+
Back
Cable Modem - I already own a modem
$CAD+
Back
DSL Modem - I'd like to loan a modem+$10 one-time shipping applied
$CAD+
Back
DSL Modem - I already own a modem
$CAD+
Back

5

Modem Questions if Owned

Hardware Model

MAC Address

Serial Number

6

Choose your Installation Date* This field is required.Please select a date more than 3 days after today

Date

7

Choose Installation Time Frame* This field is required.

7:30 AM to 12:00 PM

12:00 PM to 5:00 PM

7:30 AM to 9:00 PM

5:00 PM to 9:00 PM

8

My shipping address is the same as my service address?* This field is required.

YESNO

9

Shipping Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

10

Terms and Conditions* This field is required.

11

How was your order experience?* This field is required.

12

Optional Comments - What can we improve?Describe what we can improve to enhance the experience and we thank you in advance for your comments.

13

Please verify that you are human* This field is required.

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