PRE-AUTHORIZED DEBIT (PAD) AGREEMENT (ALL SECTIONS ARE MANDATORY)
1. CUSTOMER INFORMATION (PLEASE PRINT CLEARLY) Name: HSC Account Number: Street Address: Province:
City: Postal Code:
Country:
Telephone:
2. BANK ACCOUNT INFORMATION (PLEASE ATTACH A VOID CHEQUE) Deposit Account Number:
Branch Transit Number:
Financial Institution Number: Financial Institution:
Name: Branch Address:
3. PRE-AUTHORIZED DEBIT (PAD) DETAILS I/we authorize Hillfield Strathallan College, 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 for monthly payment for payment of all charges arising under my/our Hillfield Strathallan College account(s). Monthly payments for the full amount of services and/or goods delivered will be debited to my/our specified account on the last business day of each month. Hillfield Strathallan College will provide 10 days written notice of the amount of each regular debit. THESE SERVICES ARE FOR (CHECK ONE):
Personal
Business
This authority is to remain in effect until Hillfield Strathallan College has received written notification from me/us of its change or termination. This notification must be received at least ten (10) 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. PLEASE ENSURE ALL SECTIONS HAVE BEEN COMPLETED BEFORE SIGNING
Signature of Account Holder:
Signature of Joint Account Holder (if applicable):
Name:
Name:
(Please Print)
(Please Print)
Date:
Date:
I/we understand that 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 a Reimbursement Claim, or for more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca
When the form is complete, return along with a VOID cheque to: Hillfield Strathallan College 299 Fennell Avenue West Hamilton, ON Canada L9C 1G3
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905-389-1367
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905-389-6366
finance@hsc.on.ca