Bear Bottoms Diaper Service Application

Thank you for choosing Bear Bottoms Diaper Service. By filling out the form below you will be well on your way to starting our service. We will then call or email you to set-up your pre-birth delivery or first delivery date. It’s that easy!

Please read carefully the Terms of Service before completing this application.
Fields marked with * are required information.

I have read and accept the Terms of Service:	*
Name (First/Last):	*
Spouse/Partner Name:
Address:	*
City:	*
Postal code:	*
E-mail:	*
Home Phone:	*
Work Phone:
Cell Phone:
Best time/place to contact you:
How did you hear about us?
Expected Due Date (if applicable):
Will you require a prebirth installment of diapers?:	Yes  No
Age (in months, if born) of Child(ren) for service:
Will you be purchasing Buddi Covers?:	Yes   No Unknown
Preferred method of payment:	Pre-authorized Payment     Visa Mastercard    (Pre-authorized payment from your bank account is the most secure method of payment, VOID cheque required. Your account will be charged monthly in advance)
Invoice type:	Please indicate here if you would prefer a paper invoice. Yes   No Your invoices will be e-mailed to you monthly, prior to billing.
Questions, Comments, Gift-Cards:
By clicking below you have applied for the service and agreed to the terms within. We will contact you shortly. Thank you for choosing Bear Bottoms Diaper Service.

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Telephone: 519-634-8600     diapers@bearbottoms.ca     Toll Free: 1-877-423-2726