Peace Region Internet Society
929 106th Avenue, Dawson Creek, BC, V1G-2N9
Tel: (250)782-5128, (800)768-3311    Fax: 782-2459
You may apply to join our Society by completing this form, and forwarding it to us by mail or by fax.
Sorry, we do not generally open accounts without a signed application form.
This application form must be accompanied by a signed copy of the Agreement for Use of Internet Services
BASIC INFORMATION

Contact:______________________________
Billing Name:_________________________
Address:______________________________
City:_________________________________
Prov:____________Postal Code:_________

Date:________________________________
Home Phone:_________________________
Fax Phone:___________________________
Bus. Phone:__________________________

Age (IF UNDER 19):_______ (A Letter of Consent from Legal Guardian must accompany Application)
SERVICES REQUESTED
GST AND PST WILL BE ADDED TO ALL CHARGES
E-mail Only Account
Limited PPP Service
Full PPP Service
Casual Surfer Card
Broadband Access
Group & Corporate Service
 $10 / month or $100 / year
$15 / month or $150 / year**
$20.00 / month, $57.00/qtr, or $220 / year
$100 / 120 hours or 1 year (whichever comes first)
$28.75 - $40 / month: Separate Application required
per Agreement: TOTAL $______/[ month (or) year]
**Additional charges may apply (depending on usage) for Limited and Dedicated Services.
BILLING METHOD
Bills are e-mailed to your PRIS account
Frequency:
Monthly Billing
Quarterly Billing
Annual Billing
 Method of Payment:
Cash, Cheque, MO
[MasterCard | Visa]
Purchase Order
   If Paying by Charge Card:
Card/PO Number:___________________________Exp Date:________
Name on Card(Cardholder):________________________________

Signature of Cardholder:_______________________________


FOR OFFICE USE ONLY
Start Date: User ID: Membership #