Form - Occupants

Contact information

First name*

Last name*

Phone number (e.g. 5141112222)*

Email*

Current address or future address (if applicable)

City

Postal code (e.g. A1A2B2)

Are you already a Videotron customer?*

Yes No

If yes, would you like to add an additional service?

Yes No

By checking thix box, you agree to be contacted by a Videotron representative.*

I agree

By checking this box, you agree to the personal information collected in this form being used in accordance with the Videotron Privacy Policy.*

I agree