daves picks .pdf
Original filename: daves-picks.pdf
Title: Auto Withdrawl:Pre-Authorized Debit Form
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PRE-AUTHORIZED DEBIT / PAYMENT FORM
I, ______________________________ authorize a monthly debit from the below stated
Print Full Name (Full name on account)
account for $199.00 CDN on the ______ day of every month, beginning on the
_____ of _____, 2018, for one year (ending that same date, 2019).
(today’s date – e.g. 11th or 25th)
FINANCIAL INSTITUTION NAME: ______________________________________________
FINANCIAL INSTITUTION ADDRESS: ___________________________________________
ACCOUNT TYPE (CHECKING OR SAVINGS): _______________________
ACCOUNT NUMBER: _____________________________________________
INSTITUTION NUMBER: __________________
BRANCH TRANSIT NUMBER (5 DIGITS): ____________________________
By signing this form, you are authorizing the withdrawal of $199.00 CDN from your bank account.
$199.99 will be debited from the above specified account on the above specified date every month
for 1 year.
Today’s Date (DD/MM/YYYY)
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