Name ____________________________________________________

Connecting you, your family,

your friends... your LIFE!

Address___________________________________________________
City _________________________State_____Zip Code____________
Email____________________________Phone # __________________
Rent

Local/Long Distance Service

Current Provider __________________________________________________________________

Primary Phone Number ____________________________________________________________
My monthly bill is approximately $ __________________________________________________
Bundled with:
Internet
TV
Wireless
All
International Calls: Yes
No
Long Distance:
Yes
No
I am interested in Unlimited Calling: Yes
No

High Speed Internet Service

Current Provider __________________________________________________________________

My monthly bill is approximately $ __________________________________________________
Do you receive unlimited downloads: Yes
No
Type of Service: Cable Dial-Up DSL Wireless Aircard (Provider_______)
Bundled with:
Phone
TV
Wireless
All

Digital Phone Service

Do you call anyone who you wish you could see more often?
I am interested in Digital Phone Service (Unlimited Calling)

Do you make long distance or international calls on your mobile phone?

Are you interested in saving money on your mobile phone bill?

Yes

Yes

No

No

TV Service

Current Provider __________________________________________________________________

My monthly bill is approximately $ __________________________________________________
Bundled with:
Internet Phone
Wireless
All
Number of receivers______ Months left on contract ______
HDTV
DVR
I currently have

Home Security & Automation Service

Current Provider __________________________________________________________________

My monthly bill is approximately $ __________________________________________________
I have home security service today.
I do not have home security service today, but I am interested more information.
I am interested in Home Automation service.

Current Provider __________________________________________________________________

Energy

My monthly bill is approximately $____________

I am interested in the following: (check all that apply)

My monthly bill is approximately $_______ Minutes on plan______

Phone
TV
All
Bundled with: Internet
Total Bill $_____________
Months left on current contract ______ Number of phones on plan ______
No
Do you currently have a texting plan? Yes
Data Plan included?
Yes
No
I last upgraded my phone(s) approximately: ____ Months ____ Years

PERSON WHO INVITED ME:

COMMENTS:

Mobile Application

Current Provider __________________________________________________________________

Type of Service
Natural Gas

Electricity

Both

Wireless Service

I like my handset
I am interested in updating my handset

Own

I am interested in a wireless card for my

laptop

Residential Electricity (Ontario Only)

Residential Natural Gas (Ontario,
British Columbia & Manitoba)

Business Electricity (Ontario Only)

Business Natural Gas (Ontario, British Columbia & Manitoba)
I would like to learn more about living greener

Computer Support

Current Provider __________________________________________________________________

Do you perform a regular backup of all your files?

Yes

No
Have you ever had a computer virus?

Yes

No
Amount spent on average computer repair incident $________
Please select the type of computer support services youve used in the past
Friend or Family Member
Remote Service
National Provider
Self-help

Total Monthly Bill Amount $ _________________

$ _________________
Total Yearly Bill Amount
ACN CANADA 2012 CAENG_HSSEnergy_W_CC_032812