Service Sign-up - Lara Home Phone

Step 1: Package Options Please select your package options, username and password.

Package: Phone Only - $12.95 monthly

• 1. Do you need the equipment shipped:
  Note: $12 shipping fee would apply for each (Modem & Phone Box).
  Contact our office if the shipping address is not the same as the contact information. No - I do not require shipping. Yes - We will ship to your contact address.
• 2. Phone Details - One time fees: $60 Phone Equipment
  If your current phone provider is not Bell, we will require a Circuit ID to setup dryloop. You can obtain this information by contacting your phone provider.
• Keep Existing Phone Number: * -- please select -- No. I wish to have a new number. Yes - Keep Number $50 One Time Fee. Phone Number to Keep:
• 3. Create a Username *
  Your username is used for your high speed logon and lara email address. Maximum of 8 characters.
• 4. Create a Password *
  
• Proceed »

Step 2: Contact Information Please enter all required fields:

• 1. Full Name *
  
• 2. Company Name
  Only required if you are applying for a business.
• 3. Address Information
  Address * (please include any unit numbers or apartment numbers)
  
  City *
  
• Province/State *
  Postal *
  
• Phone *
  E-mail
  
  We will use this email address to send you signup confirmation and your monthly invoice statements. If left blank an the following email account will be created for statement purposes. You can always change this by contacting our office.
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Step 3: Billing Information Please enter all required fields. Please enter all required fields. Your account will be billed all setup and product purchase fees plus the first month service before the application will be submitted. After that it will be billed automatically monthly on the first of the month for service.

• 1. Credit Card Type *
  If you wish to choose a different payment method please contact our office. -- please select -- Visa Mastercard American Express
  
• 2. Card Holders Name *
  
• 3. Card Number *
  
• 4. Card Expiry (Month)*
  -- select month -- January (01) February (02) March (03) April (04) May (05) June (06) July (07) August (08) September (09) October (10) November (11) December (12) 5. Card Expiry (Year)*
  -- select year -- 201620172018201920202021202220232024
• 6. 3 Digit Security Code*
  
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Step 4: Order Confirmation Please review your order details and click submit to continue. We will contact you with assistance
to setup your account when the order is processed.

• Package:

  Package Term:

  Wordpress Set-up:

  Modem Option:

  Ship Modem:

  Keep Existing Phone Number:

  Phone Number to keep:

  Current Phone Provider:

  Circuit ID:

  Username:

  Password:

  Contact Information:

  Full Name:

  Company:

  Address: , , ,

  Phone:

  E-mail:

  Billing Information:

  Card Type:

• I agree to all Terms & Conditions *
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