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
Street# Street Name Street Type Direction Unit Type Unit# City Province Postal Code Country
Contact Number AlternativePhoneNumber E-mail
    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