Promotion Application Form
(This Promotion is subject to Direkchannel Products and Services only)
Customer Information
This is a referral for my friend
Title
First Name
Middle Name
Last Name
PromoCode
AgentID
Mr
Mrs
Miss
Ms
Dr
Street#
Street Name
Street Type
Direction
Unit Type
Unit#
City
Province
Postal Code
Country
Ave
Street
Road
BLVD
Cres
Circle
Drive
Court
Trail
Lane
Place
Square
Terr
Gargen
Wood
Way
None
East
West
North
South
None
Unit
Suite
APT
Ontario
Quebec
Alberta
NS
NB
MB
BC
PE
SK
AB
NL
Contact Number
AlternativePhoneNumber
E-mail
Land line
Cell phone
Products Information (Please check the box which you are interesting)
Basic Alarm Monitoring Service
* Customer use own device
* Installation Fee: $99
* Regular Price: $19.99
* No contract
Regular Alarm Monitoring Service
* Free Devices:
* Free Installation
* Regular Price: $24.99
* 3-Year Contract
Advanced Alarm Monitoring Service
* Free Devices
* Free Installation
* Regular Price: $32.99
* 3-Year Contract
Order Comment
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DirekChannel, 400 ESNA PARK DR UNIT 12, MARKHAM, ON, L3R 3K2. 2015 Edition. Internal use only. All rights reserved. 2015