SecurTek Referral Form Sales Information Sales Rep First Name * Sales Rep Last Name * PMC Location Select a Location AU PC EI FA HA MJ NI RG PA QU RO ST WA WE Customer Information Customer Name * Existing or New Customer * Select Existing SecurTek Customer Existing SaskTel Customer Existing SecurTek & SaskTel Customer New Customer ( No existing services with SecurTek or SaskTel) Customer Phone Number * Customer Email * Customer Address * Customer Address Customer Address Customer Address City City Province Province Postal Code Postal Code Services Service of Interest * Select smartHOME Automation Medical Alert Basic Security Consent to Share Information * Yes No Customer has provided their verbal consent to collect their personal information and share it with SecurTek for the purpose of discussing a home monitoring solution in further detail. Consent to be Contacted * Yes No Customer gives consent for SecurTek to share the personal information provided with a SecurTek Dealer, who requires it for an in-home consultation and fulfillment of a home monitoring solution. Additional Information Customer Expectations: You can add any additional comments/questions/etc. the Customer may have in the Additional Information field. You can also let the Customer know they can expect to be contacted by Brigadier Security Systems within the next business day. If you are human, leave this field blank. Submit
