SmokeSignalTM
Mail Address: P.O. Box 247,  Waterloo, Ontario, Canada N2J 3Z6 
Phone: 1-866-517-6390  Fax: 1-866-517-6390 
E MAIL: info@smokesignal.net
This is a Secure Site to Send Information.
Unlimited Internet:  $17.95 USA & $19.95 Can.
Name
Title*
Company*
Address
Address
City
State/Province
Zip/Postal Code
Area Code & Phone
Area Code & Fax*
Your E-mail
* optional items above 
- New Account Information -
Expert Surfers who Require Very Little Support
...... Deserve to get a better price !
(GST Taxes are extra for Canadian orders when applicable)

Select the items that you would like:
We offer an "a la carte" service....Order only what you need.
(Please check all that apply)
General Information Request
Have a Rep Contact me by email. I need more info.
Provide me with Dial up numbers in my Area.
Send me some detailed info about your Web Site Service.
I need info about Web Site Design Service.
Additional information:
Invoice my Company for the Payment. (Service will commence on payment paid by method below). I need an invoice sent to my company for tax purposes. 
I want to start the service on the date indicated in the Special Request box below. (Note: we prefer to start each account on the 1st of the month to streamline the accounting process).
I need information concerning the transfer of my Domain Name to your server. Please send your setup Info and DNS numbers. 
I would like to order a new domain name. Can you assist me? 
I have a Win95/98/ operating system. 
I have a Win/NT operating system. 
I have a Mac operating system. 
I have an OS/2 operating system. 
I have a Linux operating system.
- Order & Payment Methods -
USA Resident Customers 
Sign me up for Unlimited 56Kv90 in the USA. $17.95 US/mth.
I need a Business Web Site at 10.00 US/mth. $30.00 US one-time setup fee. 
     ( Web Sites run on high speed OC3 connections /24hr/7day. )
One Secure E Mail POP account included. Extra E Mail alias names...free.
I need an Extra Secure E Mail account. $3.00/mth. US 
Canadian Resident Customers Only
Sign me up for Unlimited 56Kv90 in the Can. $19.95 Can./mth.
I need a Business Web Site at $10.00 Can./mth. $45.00 Can. one-time setup fee. 
     ( Web Sites run on high speed OC3 connections /24hr/7day. )
One Secure E Mail POP account included. Extra E Mail alias names...free.
I need an Extra Secure E Mail account. $3.00/mth. Can.
Payment Method
Check / Cheque / Money Order ( Mail to the address at the top of form )
Direct Bank Deposit ( We will email bank deposit numbers )
Or by;
I am paying by US Credit Card in US funds. ( USA resident. )
I am paying by Can. Credit Card in Can. funds. ( Can. resident. )
Secure Credit Card Authoization
Select a Credit Card
VISAMasterCard
( GST Taxes extra for Canadian orders when applicable )
Note: We will confirm the exact amount to be charged prior to setup.
Account Card #:
Expiration Date:
Cardholder Name:
Payment Activity:
( See below )
Describe your intention for Payment Activity above:
eg; one-time payment, or
withdraw monthly credit card payment on the 1st of mth., or
contact me for future card authorization, etc.... 

Do you have any other special request?

Please describe: