Pre-Authorized Banking Payments - Water and Sewer Utility

Pre-Authorized Banking Payments - Water and Sewer Utility
I hereby authorize the City of Miramichi to charge the amount equal to the quarterly water and sewage invoice (pay on due date), for the following address, to the bank account indicated below:
12 Digit Water/Sewer Account Number:*
Name

First NameLast Name
Property Owner (if different from above):*
Service Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different from Service Address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Email
example@example.com
Payment Schedule

If you would like payments to be processed for an amount other than the amount due, please specify the payment amount and date(s)below:
Payment Date/Frequency:

1st of the Month15th of the Month30th of the Month
Payment Amount:
Banking Information

Please provide the banking information for the account you'd like debited.
Bank:
Transit:
Account:
PLEASE UPDATE A COPY OF A VOID CHEQUE
Upload your void cheque here:

Cancelof
Property Owner Signature:

Clear
Should be Empty:

Payment Schedule