pre-authorized donaon form - veteran camp · 2018. 3. 12. · pre-authorized donaon form a...

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Pre-authorized dona/on Form A pre-authorized dona/on (PAD) allows you to make a monthly dona/on, directly from your bank account You choose the monthly amount $ (Fill in your amount here) What day of the month to take this amount out? ADach a voided cheque, with the word VOID clearly wriDen on the face of the cheque or account informa/on as follows: Transit Ins/tu/on Account# Also include the following informa/on: Name: Address: Street: City: Province: Postal Code: Telephone: Cell: I, the undersigned: • Cer/fy that the informa/on on this form is true and correct • Consent to the exchange of this informa/on for the purpose of an debit transfer/credit card transac/on between Veteran Full Gospel Camp Associa/on and myself for the amount noted above. • Understand that the use, disclosure and storage of this form remains the responsibility of myself and/or the direct debitor. Signature: Please mail this completed form to PO Box 2151 SteDler, AB T0C 2L0 Receipts will be issued at year-end.

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Page 1: Pre-authorized donaon Form - Veteran Camp · 2018. 3. 12. · Pre-authorized donaon Form A pre-authorized donaon (PAD) allows you to make a monthly donaon, directly from your bank

Pre-authorizeddona/onForm

Apre-authorizeddona/on(PAD)allowsyoutomakeamonthlydona/on,directlyfromyourbankaccount

Youchoosethemonthlyamount $ (Fillinyouramounthere)

Whatdayofthemonthtotakethisamountout?

ADachavoidedcheque,withthewordVOIDclearlywriDenonthefaceofthecheque

oraccountinforma/onasfollows:

Transit Ins/tu/on Account#

Alsoincludethefollowinginforma/on:

Name:

Address:

Street:

City:

Province: PostalCode:

Telephone: Cell:

I,theundersigned:

• Cer/fythattheinforma/ononthisformistrueandcorrect

• Consenttotheexchangeofthisinforma/onforthepurposeofandebittransfer/creditcardtransac/on

betweenVeteranFullGospelCampAssocia/onandmyselffortheamountnotedabove.

• Understandthattheuse,disclosureandstorageofthisformremainstheresponsibilityofmyself

and/orthedirectdebitor.

Signature:

PleasemailthiscompletedformtoPOBox2151SteDler,ABT0C2L0

Receiptswillbeissuedatyear-end.

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