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Personal Wellness Program Application

  1. Full Name:(*)

    FirstInvalid Input

    LastInvalid Input

    MiddleInvalid Input
  2. Address:(*)
    Invalid Input
  3. Address Line 2 (Optional):
    Invalid Input
  4. Parish:(*)
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  5. Zip Code:(*)
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  6. Home Phone:(*)

    HomeInvalid Input

    CellInvalid Input
  7. Birthdate:(*)
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  8. Email:(*)
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  9. Driver's Licence or Passport Number:(*)
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  10. How many devices are you registering?
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  11. Device(s):(*)

    Product Type (*)Invalid Input

    Serial Number (*)
    To Find Serial Number:
    Settings --> General --> About --> Serial Number
    Invalid Input

  12. Product Type (*)

    Serial Number (*)Invalid Input

  13. Product Type (*)

    Serial Number (*)Invalid Input

  14. Product Type (*)

    Serial Number (*)Invalid Input

  15. Product Type (*)

    Serial Number (*)Invalid Input
  16.  
  1. Plan Choice:(*)


    • - $10 per month, per device/ $50 per repair
    • - iPhone, iPad, iPod repairs
    • - **Screen Repairs
    • - Hardware and Software repairs
    • - Data Extraction
    • - Pick-up and delivery within the city of Hamilton
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    • - $110 per year, per device/ $50 per repair
    • - iPhone, iPad, iPod repairs
    • - **Screen Repairs
    • - Hardware and Software repairs
    • - Data Extraction
    • - Pick-up and delivery within the city of Hamilton
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  2. *$100 Cancellation fee will be applied if any repair has been completed and the customer wishes to cancel within a year of their sign-up date. Cancellations will have a 30 day notice period.

    **Customers are afforded a maxiumum of four screen repairs per year.

  3.  
  1. Cardholder Name:(*)
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  2. Payment Type:(*)
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  3. Card Number:(*)
    Invalid Input
  4. Expiry Date:(*)

    MonthInvalid Input

    YearInvalid Input
  5. CVV:(*)
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    Three digits on the
    back of your card.
  6. Invalid Input
    Invalid Input
  7. Billing Address:(*)
    Invalid Input
  8. Billing Address Line 2 (Optional):(*)
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  9. Parish:
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  10. Zip Code:(*)
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  12. How did you hear about us?
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  13. Invalid Input
  14. Anti-Spam(*)
    Anti-Spam Invalid Input
  15.