Request Gold Bell Membership

Thank you for choosing Gold Bell Membership. Please complete and submit this form electronically or call us at 416-922-1423 or 1-888-922-1423 and register by phone.

This is a Secure Form

Please provide the following contact information (* = required)

First Name:	*	Last Name:	*
Title:	Miss Ms. Mrs. Mr. Dr.	Name you like to be called:
Home Phone:	*	Work Phone:
Fax:		Email:	*
Company Name (if applicable):
Street:	*
Apartment/Suite:
City:	*	Province:	Ontario
Postal Code:	*

Create your login ID (* = required)

Username:	*	Password:	*
		Password Confirm:	*

Credit Card Information (* = required)

Billing Period:	1 Year 12 Months *
Type:	Visa: MasterCard: American Express: *
Full Name on Card:	*
Credit Card Number:	*
Expiry Date:	*

GOLD BELL MEMBERSHIP TERMS

Your Gold Bell Membership to Concierge By Request is for a 12-month period at the rate of $210 per annum. You may make a one-time payment or agree to have your credit card debited in 12 equal monthly payments of $17.50 each. GST applies to both modes of payment.

By agreeing to the Gold Bell Membership Terms you give Concierge By Request the right to bill your credit card for the annual fee, based on the payment option you chose. Services and products purchased during the life of the agreement will be automatically billed to your credit card unless you request another form of payment.

All information provided to Concierge By Request will be managed in accordance with our privacy policy.

I accept the Terms of Membership
I do not agree

If you have any questions, please call us at 416-922-1423 or 1.888.922.1423

Thank you.