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Account #

Contract Sign Date*

I am:*

a new customer
an existing customer moving to a new address
an existing customer and want to add another address

When do you want service to start?*

Minimum is 10 days from today's date.

Agent Number

Referral Code/Membership Number

AMA Number

Lyoness Number

Facebook Discount Number

Choose Your Products

Do You Require Electricity?*

No electricity required
Yes, I need electricity

ELRF

ELRF-Fixed

ELAF

ELAF-Daily

Do You Require Natural Gas?*

No natural gas required
Yes, I need natural gas

NGRF

NGAF

Do You Require Internet?*

No internet plan required
Cable Internet Unlimited 30 - $59/month
Cable Internet Unlimited 75 - $69/month
Cable Internet Unlimited 150 - $79/month

Energy Product Options

Electricity Price*

Wholesale plus $0.012/kWh
Fixed at $0.0629/kWh

Electricity Price (Business)*

Wholesale plus $0.009/kWh
Fixed at $0.629/kWh

Electricity Price (Discounted)*

Wholesale plus $0.011/kWh
Fixed at $0.619/kWh

Does Your Electricity Site Require Energization?*

(Currently you have no power)

Yes
No

Electricity Site ID (if known)

Natural Gas Price*

Wholesale plus $0.99/GJ

Natural Gas Price (Business)*

Wholesale plus $0.89/GJ

Natural Gas Price (Discounted)*

Wholesale plus $0.89/GJ

Does Your Natural Gas Site Require Energization?*

(Currently your natural gas is disconnected)

Yes
No

Natural Gas Site ID (if known)

Internet Product Options

Do you require a wireless router? A wireless router is required for wifi use.*

Yes
No

Is Shaw your current internet provider?*

Yes
No

Your Details

Primary Contact*

First Last

Date of Birth (For the credit check)*

Business Name (optional)

Secondary Contact

First Name Last Name

Your Email Address*

Primary Phone Number*

Primary Phone Extension

Secondary Phone Number

Secondary Phone Extension

Mailing Address

Mailing Address Type*

Civic
PO Box
Rural Route
General Delivery

Unit #

House #*

Pre Street Direction

Street Name*

Street Type*

Street Direction

PO Box #*

Lot ID

Site Number

Compartment/Box

Rural Route Identifier*

Rural Route

Suburban Service

Mobile Route

Station Type

LCD Name*

RPO Name*

STN Name*

Pre Road #

Road Type

Post Road #*

General Delivery*

City or Municipality*

Province*

Postal Code*

Is the service address the same as the mailing address?*

Yes
No

Service Address

Service Address Type*

Civic
Legal Land
Rural Route

Unit #

House #*

Pre Street Direction

Street Name*

Street Type*

Street Direction

Lot ID

Site Number

Compartment/Box

Rural Route Identifier*

Rural Route

Suburban Service

Mobile Route

Station Type

LCD Name*

RPO Name*

STN Name*

Pre Road #

Road Type

Post Road #*

City or Municipality*

Province*

Legal Land Description

Quarter

LSD

Section

Township

Range

Meridian

Land Title

Lot

Block

Plan

Terms and Conditions

I have read and agree to the Terms and Conditions. I acknowledge that I have read the Disclosure Statement contained in the Terms and Conditions, and understand its contents.

I agree to these terms and conditions:*

Yes

Comments

Do you have any additional comments or questions?

Payment

Thank you for completing our online enrolment form. Since payments for our accounts are completed by pre-authorized bank withdrawal, we will need a copy of your bank details.

Click the following button to finish the application by setting up your payment information. Please note that your application will not be processed until we receive your payment information.

Phone

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