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Items with an asterisk (*) are required and must be filled out before the form can be submitted. Once your submission is received, a WCCT representative will follow up with you to answer any additional questions that you might have about the service to be provided and pricing.

Customer Information and Service Address

First Name*

Last Name*

Primary Phone Number*

Other Phone Number

Email*

Street*

PO Box / RR#

City*

Province*

Postal Code*

Do you currently have internet service at this location?*

Yes

No

Allow WCCT to share name, address and home phone number with phone directory publishers

Yes

No

Phone Information

Current Provider

Phone Number

Account Owner

Account Number

Phone Address Info

Same as Above

Phone Account Address

Phone Account Street

Phone Account PO Box

Phone Acct City

Phone Acct Province

Phone Acct Postal Code

Billing and Payment Information

Invoice Delivery*

Financial Institution*

Payment Option*

Billing Address Info

Same as Above

Billing Address

Billing Street

Billing PO Box

Billing City

Billing Province

Billing Postal Code

Customer Notes

Additional Information

Allow WCCT to send communications (bill information, notices, and newsletters) by email

Yes

No

Customer Approval

This field should be left blank

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