BrantfordWeb.net
A Galganov & Associates web site
To renew your BrantfordWeb.net Website, please complete the form below and fax it to:
Galganov & Associates
Tel.: (519) 752-5381 " Fax: (519) 752-3088

I have read and agree to the terms as posted at
https://BrantfordWeb.net/terms.html

Company name: ______________________________________________

Your name: __________________________________________________

Address: ____________________________________________________

City: _______________________________________________________

Province: _________________________ Postal Code: _______________

Web Site Name: ______________________________.BrantfordWeb.net

E-mail: _____________________________________________________

Telephone No: (_____) __________________

Date: ________________________________

One Year Subscription = CAD 250.00 + 17.50 GST (7%) = $267.50
G.S.T. #888433661

Credit Card Type: VISA MasterCard

Name on Card:______________________________________________

Cardholder Address:__________________________________________

___________________________________________________________

Credit Card #:_______________________Expiration Date:___________

Last 3 digits of number printed on back of the credit card:____________

Signature:_______________________________Amount: $____________


Close Window | Print This Form

Copyright © 2003 Galganov & Associates