Authorization for Pre-Authorized Debit Plan Payer(s) Financial Institution / Banking InformationCopy of Void Cheque(Required)Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.Name of Financial Institution:(Required) Bank I.D. Number:(Required) Account Number:(Required) Transit Number:(Required) Account Type(Required) Chequing Savings Branch Address(Required) Street Address City Province Postal Code VOID Cheque must indicate the following information:Payer(s) InformationPayer Name(s):(Required) Phone Number:(Required)Address(Required) Street Address City Province Postal Code Childcare services for:(Required) Child’s Name(s) Type of Service:(Required) Personal Business Type of Cost:(Required) Regular Intermittent Authorization for Pre-Authorized Debit Plan(Required) I agree to the Pre-Authorized Debit (PAD) Plan agreement below.I/we authorize NorthAlta Family Day Care Services Ltd., and the financial institution designated (or any other financial institution I/We may authorize at any time) to begin deductions as per my/our instructions and contract for monthly regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our NorthAlta Family Day Care Services Ltd account(s). Regular monthly payments for the full amount of childcare services received will be debited to my/our specified account on the 1st day of each month. NorthAlta Family Day Care Services Ltd. will obtain my/our authorization for any other one-time or sporadic debits. This authority is to remain in effect until NorthAlta Family Day Care Services Ltd. has received written notification from me/us of its change or termination. This notification must be received at least twenty (20) business days before the next debit is scheduled at the address provided below. I/We may obtain a sample cancellation form, or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting www.cdnpay.ca. NorthAlta Family Day Care Services Ltd. may not assign this authorization, whether directly or indirectly, by operation of law, change of control or otherwise, without providing written notice to me/us. I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD agreement. To obtain a form for Reimbursement Claim, or for more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca Authorized Signature (Primary):(Required)Authorized Signature (Joint):
