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Name

Province

City

Address

Postal Code

Current
Telephone Num

Current Phone
Company

Please assign me a new telephone number in thisCity

My 2nd Line

Please assign me a 2nd
Number in this City

Present Internet
Provider

I wish to keep this telephone number (A $5.00 charge applies)

I have an alarm system that uses my telephone line

I would like to remain
with this provider

I wish to keep this telephone number (A $15.00 charge applies)

Reseller

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