Odynet Sign-up form

Please fill in the following infomation and click on the Submit button at the bottom of the form.
Your request will be processed and you will be contacted with the details of the installation.

First Name
Last Name
Company Name
Email Address
Address 1
Address 2
Postal Code
Contact Phone

Service Type

Modem Options
** Rentals require a refundable $25.00 Deposit **
Phone Provider
* If using Primus or Other Reseller, Provide Circuit "ckt" number in notes.
Provider Line

Payment Method
(Visa, Amex or Mastercard)
Credit Card info:
Card Number
Card Expiration
Month: Year:
Pre-authorized payment info:
Account #
Transit #
Bank #

Additional Info/Requests:
We'd like to know how you heard about us?