Please fill out the form below in order to register your Product Protection Plan. Use the sample receipt on the right as a guide in filling out this form. NOTE: The information will be provided to the Product Protection Plan administrator. All fields with an asterisk (*) are required.

Receipt Information 
Store Number *
Transaction Number *
Plan Number *
Date of Purchase *
Customer Information 
First Name *
M.I. 
Last Name *
Address 1 *
Address 2
City: *
Province *
Postal Code * (XXX XXX)
Phone * ( )    Ext.
Alternate Phone ( )    Ext.
E-mail Address
Product Information 
Product Number *
Manufacturer *
Product Category *
Model Number
Serial Number  
Product Price *
 Excluding Taxes