Pre-authorized Debit Agreement
Good Spirit Bible Camp
First and last name of account holder.
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
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example@example.com
Phone Number
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Format: (000) 000-0000.
The name of the financial institution where the account is located
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Institution number
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Transit number
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Account number (with check digit)
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I, the undersigned, (if a legal person, herein represented by its duly authorized representative(s)), authorize the Payee to make pre-authorized debits (PAD) from my account with the aforementioned financial institution, at the following interval (monthly):
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Beginning on the 1st of the month
Beginning on the 15th of the month
Each withdrawal will correspond to (choose one of the options below)
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A variable amount, of which I must be advised by the Payee in writing at least 10 days before the due date.
A fixed amount to withdraw each interval, which may be increased without any further authorization on my part, provided that the Payee notifies me in writing at least 10 days before the due date of the payment.
Please input your fixed amount below
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Waiver: (please check these)
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I hereby waive the aforementioned written notice of 10 days.
I have received a copy of this Agreement and waive all other confirmation before the first payment.
Signature
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