I/We want to support Bhavani Shankar Mandir through monthly donations
Donor Information
Name
First Name
Last Name
Address
Street Address
City
State / Province
Postal / Zip Code
Primary Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail address
example@example.com
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Bank Account Information
Deposit Account Number
Choose Account
Chequing Account
Savings Account
Financial Institution Number
Financial Institution Name
Branch Transit Number
Branch Address
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Pre-Authorized (PAD) Details
You, the donor, authorize Bhavani Shankar Mandir to debit the bank account identified above for: (select the applicable amount) on the 6TH DAY OF EVERY MONTH, OR THE NEXT BUSINESS DAY
$20
$25
$50
$100
Other (Specify)
This donation is made on behalf of:
An individual
A business
You, the donor, may revoke your authorization at any time in writing, or by phone, subject to providing notice of 10 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.cdnpay.ca
Signature of Account Holder:
Name of account holder
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Joint Account Holder (If Applicable):
Name of joint account holder (if applicable):
First Name
Last Name
Date (if applicable)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or not consistent with this PAD agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.cdnpay.ca
Submit
Should be Empty: