Prepaid Long Distance Service

Between DCI Telecom, Box 62, Saint-Laurent, Quebec, H4L 4V4, and the Customer as identified below
Application for Prepaid Long Distance Service
Are you applying for residential or business service?
If you checked "business" please list the name here
Enter your first & last name
Enter your street address
Enter your City, Province & Postal Code
Enter your phone number
Enter your fax number
Enter your cellular number
to ID yourself when you call us
a valid email is required
How did you hear about DCI?

Prepaid Services To Activate

Please indicate the amount of your payment. We will charge your credit card the indicated amount + applicable sales taxes.
If 1+ Access is selected, I authorize DCI Telecom or its assignee, to switch my primary long distance service to DCI and to notify my local telephone company to effect the change. I agree to pay the monthly access charge indicated above and confirm that I am at least 18 years of age and authorized to make changes on the above lines. I understand that this authorization switches all direct dialed long distance calls to DCI Telecom.
A great way for family members to stay in touch. Only 4 cents per minute.
Please list all phone numbers FROM which calls will ORIGINATE sperated by a comma
Please list your top 5 countries where you call most

Credit Card Information

Please write your name as it appears on the credit card
Enter your card number.
By providing my credit card number, I hereby authorize DCI Telecom Inc. and/or its assignee, to debit this credit card for the transaction indicated above and any other amounts ensuing from this agreement. Each charge shall be treated the same as if I had personally issued a written direction authorizing DCI Telecom Inc. to bill/charge the amount specified to the above listed credit card account

DCI Telecom Inc., Box 62, St. Laurent, Quebec, Canada, H4L 4V4
By clicking the submit button below, I, the undersigned, confirm that I wish to purchase DCI Telecom prepaid long distance services in the amount indicated above and certify that all above information is true and complete. I understand that this order is subject to acceptance by DCI Telecom Inc. I agree to read and be bound by the Terms and Conditions of the respective DCI Telecom product or service selected. I will not disclose my PIN number, access code(s) and/or instructions to any third party, and understand that use of DCI's services shall evidence receipt and constitute acceptance of the terms and conditions of this agreement which shall be governed by the laws of the Province of Quebec. It is the express wish of the parties to use the English version of this contract and that this agreement and any directly or indirectly related documents be drawn up in English. Les parties ont exprimé la volonté expresse d’utiliser la version anglaise de ce contrat et que cette convention et tous les documents s'y rattachant directement ou indirectement soient rédigés en anglais.