to a copy of the TFC Application form

R*ised:Januory,201 5
APPLICATION DATE
IPTV Subscription Form
Month
Day
Dealer's Name:
Dealer Code:
AGENT:
Dealership Phone No.
PromoTitle:
AGENT Code:
STEP 1: SUBSCRIBER INFORMATION
NAME OF SUBSCRIBER
Last Name
Middle Name
First Name
CONTACT INFORMATION
Home Landline
Mobile Phone
(optional)
Date of
EMale EFemale
Office Number
Birth:
/
_l
Month Day
_
%n
F mail Address
Fax Number
.
(optional)
GENDER:
BILLING ADDRESS
Suite/Apt.#
Street
Province
City
Postal Code
SHIPPING ADDRESS (if differentfrom billing address)
Suite/Apt.#
Street
Province
TF( PA(KAGE (Select 0ne)
Buzer #
529.95.
ure
s19.95-
select one)
I I PLUS:
lsno trurEsrYlE trcoc trt,ttyllv
522.95.
f
s8.es.
(must
lrrrsrvlr
5hipping & Handling
nflotiIF(sub$ib€r n
A(tivation
lsro.os flwuvro n
Fee
*5ubje.ttoterms
lsroo.oo-af8,E[,,
and condition5olthesubscription
Provided by Dealer:
( f no,STBw
I
((he(k)
Card
form€rrt(subdber
oiient tubrdber, pl€a*
indi(ate TF( prcviden
IoblAmountR(etoed byDeils
s
[0.
lfYES,
what ir the
SPEED
Yes,
lwish to have my credit card debited for monthly subscription
on my TFC Account
E Horn" E
Others:
(Pls. specify)
PRE-AUTHORIZED PAYMENT (Bank Account lnfo)
Ma( l,lo.
f] YES tr
NO
B. Whois yourintemel ser!ice providerl
in yourarea
otyourservice/
be
app ed f you opl to pay lu(eedmq prymeni5 v
a
deb t
nn
nqement from
yor
ba
nk
a(ount. f Bt month tsyment howpvtr, w
I be v a rred t GId or
M{Mbff)
Note: A speed of 2 Mbps is required for the STB to operate
Cheque marked "void" attached. Pls. do not indicate any date or amount.
!
effciently
STEP 5: SUBSCRIBER AUTHORIZATION
signed by me.
information in conn€dion with the transfer byABS-IBN (anada ULt 0f its business
information
!
I
0n this
to anysu(essor.
applicti0n f0rm.
authorize AB5 (BN (ana da
U
Lt t0 send my
bi
ing
on I ine wh
ich I ran a(cess using inf0rmation (edentia
s em
a
iled to me dire(tly by
A
85 tBN (anada
ll
L(.
acceptancebyAB5-[BN(anadaULt. However,theapplicationshall(onstitutefi]yagreementtosubscribet0theaboveserviceinaccordancewiththetermshereof,
MM/DD/YY
csh.)
lAVe authorize AB5-CBN Canada ULC and the financial institution designated on the
voto cneque arracneo, Io oegtn monrnty oeoucltons ror paymenr or ail cndrges d15rn9
under my/ourTFC Subscription.This authority is to remain in effect until ABS-CBN
Canada has received written notification from me/us of its termination in time to allow
ABS-CBN Canada reasonable opportunity to act on it, or until ABS-CBN Canada has sent
me/us written notice of termination of this agreement.
(ONNEfiION DTTAITS:
internet5erli(e provider
E
0ther
(Io
N0, you may contact a lo(al
ves, I wish to have my credit card debited for the purchase of one 5TB
y
beforsh Dment)
A.Doyouhaveexistinglnternet?
!
CREDIT CARD BILLING ADDRESS
*Tax$app
STEP 4: HIGH-SPEED INTERNET CONNECTION
lf
Holderl Name:
Fvninr llatp'
table:
agreement
_yrs.
Credit Card No.
CuilentTF(sub5ciber
lf former or
Set Top 8ox (5TB)
- INFORMATION: ! tnitial ! Monthly
visa
E
E Mastercard n nmr* E others
CREDIT CARD
{(he(kon€ if appli(able)
]sus.oo Iwnrvro
Fee
STEP 3: SUBSCRIBER PAYMENT INFORMATION
MONTHLY SUBSIRIPTION FTE
enrrururvr
ff
STB
City
Postal Code
STEP 2: SUBSCRIPTION DETAILS (Please choose the subscription package that you want)
I
!
-
Subscriber's Name (Print)
Dealer: Kindly send this form via Post Mail, FAX or E-Mall at:
ABS-CBN Canada U LC, 300 Consiliu m Place Suite I 05 Sca rboroug h ON M 1 H 3G2
FAX: 1-800-832-2998 (1-80o-TFC-2998) E-Mail at: customerserviceCA@abs-cbni.com
.
your
Subscriber's signature
lPMoxwillautomati(ally
. All (onditions expalined and
b€
adivated on the 8th dayafter re(eiving the box.
undertood.
(ustomer I nitia ls: