Direct Debit Form

Personal Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Details
Bank Name
Transit Number (5 Digits)
Bank Financial Institution #. (3 Digits)
Account Number (7 Digits)
Amount to be debited monthly ($) on the 15th of each month
Monthly Pre-Authorized Information:
I’ve supplied the correct information below. This authorization may be cancelled at any time, subject to providing written notice of
at least 10 business days before the next charge/debit is scheduled. To obtain a sample cancellation form, or for more information
on my right to cancel a PAD Agreement, I may contact my financial institution or visit www.cdnpay.ca.
Authorization
I authorize Kids On Track to direct debit my monthly donations on the 15th of the month.
I have certain recourse rights should any debit not comply with this agreement. For Example, I 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 my recourse rights, I may contact my financial institution or visit www.cdnpay.ca
Void Check

Cancelof
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Personal Information