Pre-Authorized Debit (PAD)
Authorization Form
Bank Account Holder Name:
*
First Name
Last Name
Email
*
example@example.com
Financial Institution Name:
*
Financial Institution Number
*
must be 3 numbers - no spaces
Account Number
*
must be only numbers - no spaces
Transit Number
*
must be 5 numbers - no spaces
Type of Bank Account
*
Chequing Account
Savings Account
Donation Amount (CAD)
*
$20
$50
$100
$250
Other
Bank Phone Number
-
Area Code
Phone Number
Bank Branch
City, State
Signature
*
Date
*
/
Month
/
Day
Year
Date
Enter the message as it's shown
*
Submit
Submit
Email PDF of PAD to:
example@example.com
Should be Empty: