VTN Registration Form

By: Victoria Telecommunity Network  09-12-2011

VICTORIA TELECOMMUNITY NETWORK
220 - 4252 Commerce Circle
Victoria, British Columbia V8Z 4M2 Canada
Telephone:  (250) 727-7057 email:

REGISTRATION FORM

PLEASE PRINT, complete and send this form to the above address, once you have registered Online.

I have read the User Agreement provided on the system.
I agree to abide by all the rules and regulations contained within it.
I further state all information provided for the creation of this account is truthful and accurate.

____________    ____________________
Date                     Signature of user

______________________     ______________________
Print                                          Signature
*Signature of Parent/Guardian if user is under 18 years*

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Name: _______________________________________________________

Address: ____________________________________________________

City: ______________________________ Province: _________________

Postal Code: ___________ Country (if not CANADA): ________________

* User ID: _____________________

Telephone office: ______________ Telephone home: _________________

E-mail address (other than Victoria Free-Net): _____________________

=+=+=+=  PLEASE INCLUDE a photocopy of your driver's  =+=+=+=
=+=+= licence, or utility bill, etc. to validate your identity. =+=+=

The following information is requested in case you should lose your ID or password. It will allow us to identify that you are really you.

THIS INFORMATION IS CONFIDENTIAL.

Mother's Maiden Name: _____________ YOUR Date of Birth: ______________

DONATION/MEMBERSHIP: VTN is a community-based computer information system. Financial contributions from users (donations and memberships) support this system (more information below). Thank you for your interest and support.

Please find enclosed my donation of: $ ____________
I wish to become a member of the Victoria Free-Net Association
- membership fee $25.00 yearly $ ____________
Total enclosed $ ____________

(cheques should be made payable to "Victoria Free-Net Association")   (2005-Apr-12)

The information in this article was current at 06 Dec 2011


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