Pre-Authorized Debit Agreement

First Name*

Last Name*

ACMDTT Registration #*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number *

(xxx-xxx-xxxx)

Name of Financial Institution*

Five-Digit Transit/Branch #*

Three-Digit Financial Institution #*

Account #*

Account Type*

Your bank account will be automatically debited as outlined in the payment schedule below, with the first payment withdrawn on March 15, 2026. 

2026
Mar. 15	Apr. 15	May 15	Jun. 15	Jul. 15	Aug. 15
$75.00	$75.00	$75.00	$75.00	$75.00	$75.00

Variable Payment Amount and Dates: 

In the event that PAD program fees change (renewal or administrative), you will be notified and your PAD will be adjusted accordingly.
If a PAD is returned NSF, a second attempt will be made five (5) banking days later. If the second withdrawal attempt returns NSF, a $105.00 payment is required ($75.00 PAD payment + $30 NSF fee) to remain on PAD. The College will contact you with details.
PAD Category: Business

The Pre-Authorized Debit (PAD) Agreement is subject to the terms and conditions below:

1. Authorization. I/We hereby authorize the Alberta College of Medical Diagnostic and Therapeutic Technologists (the College), in accordance with the terms of my/our account agreement with Financial Institution, to debit or cause to be debited the Account for the purposes indicated above.

2. Waiver of Pre-Notification. I/We hereby waive any and all requirements for pre-notification of debiting.

3. Changes to Account. I/We undertake to inform the College, in writing, of any change in the Account information provided in this Agreement 14 days prior to the next due date of the PAD.

4. Cancellation. This Authorization is continuing but may be cancelled at any time upon 30 days’ notice being provided by me/us, either in writing or orally to the College, with proper authorization to verify my/our identity. I/We acknowledge that I/we can obtain a sample cancellation form or further information on my/our right to cancel this Authorization from Financial Institution or by visiting www.cdnpay.ca.

5. Contact. I/We acknowledge that if I/we wish to cancel this Authorization or if I/we have any questions or need further information with respect to a PAD, I/we can contact the College.

6. Other Agreements. Revocation of this Authorization does not terminate any other contract that exists between me/us and the College. This Authorization applies only to the method of payment.

7. Delivery. I/We acknowledge that provision and delivery of this Authorization to the College constitutes delivery by me/us to Financial Institution.

8. Verification. I/We acknowledge that Financial Institution is not required to verify that a PAD has been issued in accordance with the particulars of this Authorization, including, but not limited to, the amount. I/We acknowledge that Financial Institution is not required to verify that any purpose of payment for which the PAD was issued has been fulfilled by the College as a condition to honouring a PAD issued or caused to be issued by the College on the Account.

9. Recourse. 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 is not consistent with this PAD Agreement. To obtain more information on your recourse rights, contact your Financial Institution or visit www.cdnpay.ca.

10. Personal Information. I/We consent to the disclosure of any personal information that may be contained in this Authorization to the Financial Institution that holds the account of the College to be credited with the PAD to the extent that such disclosure of personal information is directly related to and necessary for the proper application of Rule H1 of the Rules of the Canadian Payments Association (CPA).

By completing the signature fields below, I confirm that the bank information provided is accurate and that I am authorized to provide this information for the purposes of debiting the bank account provided, as per the terms listed in this document.

By completing the signature field below, I confirm that the my existing bank information is accurate and that I am authorizing the College to continue my enrolment in the PAD program, as per the terms listed on the College website.

I hereby confirm my request to withdraw from the PAD Program by completing the signature field below.

Account Holder Name: *

First NameLast Name

Today's Date:*

Date

Signature of Account Holder*

Signature*

Please upload matching Photo ID*

Browse Files

Photo ID can be a government Identification card, driver's license or passport. ID must be not expired. (pdf, jpg, jpeg, png, gif)

Name of Joint Account Holder (If Applicable)

First NameLast Name

Today's Date:

Date

Signature of Joint Account Holder (If Applicable)

By clicking “Submit” below, you agree to the terms and conditions above. If successfully submitted, a thank you page will appear.

At least three days before your first withdrawal in March 2026, you will receive written confirmation by email that you have successfully entered the PAD program.

Pre-Authorized Debit (PAD) Program Renewal/Enrollment

Pre-Authorized Debit (PAD) Agreement

Personal Information

Personal Banking Information

Payment Details

PAD Terms & Conditions

Acknowledgement & Signature