Pre-Authorized Debit (PAD) Plan

Please complete the Pre-Authorized Debit (PAD) Plan agreement below.

1. Customer Information (Please print clearly):

Name: *

Mailing Address: *

City:

Province:

Postal Code:

Telephone Number:*

E-mail Address: *

2. Bank Account Information:

Financial Institution Number (3 Digits): *

Deposit Account Number: *

Branch Transit Number: *

Financial Institution Name: *

Financial Institution Branch Address: *

Cheque AccountSaving Account

3. Pre-Authorized Debit (PAD) Details

You, the Payor, authorize $amt to debit the bank account identified above for frequency each time that the value of the services you have purchased, including applicable taxes, reaches the amount.

These services are for (check one) personal business use.

You, the Payor, may revoke your authorization at anytime, subject to providing notice for 30 days. To obtain a sample cancellation form, or for more information on your right to cancel a PAD Agreement, contact your financial institution or visit www.payments.ca

Signature of Account Holder :*

Name: *

Date: *

Signature of Joint Account Holder (if Applicable):

Name:

Date:

You have certain recourse rights if any debit does comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consitent with this PAD agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.payments.ca

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