VICTORIA TELECOMMUNITY NETWORK
220 - 4252 Commerce Circle
Victoria, British Columbia V8Z 4M2 Canada
Telephone: (250) 727-7057
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
______________________ ______________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
*Signature of Parent/Guardian if user is under 18 years*
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
- membership fee $25.00 yearly $ ____________
Total enclosed $ ____________
(cheques should be made payable to "Victoria Free-Net Association") (2005-Apr-12)