INTERNATIONAL MEDICAL HEALTH ORGANIZATION(Canada) IMHO Canada Request for Direct Debit Payment Plan Bank Name No./St. Name / Suite No.: Bank Address City:
Prov:
Branch No.
Swift No.
Type of Acct.
Pos. Code: Account No.
Chequing
Savings
Other(specify)
Title / Name(s) of Account As a convenience to me , I hereby authorise you to debit the amount, as stated below, from my account. I hereby attach a voided cheque. I would like to contribute: $ 25.00
Monthly
$ 50.00
Quarterly
$ 100.00
Biannually
$ 500.00
$1000.00
Annually
Other :$
Name Address City: Phone No.:
Signature:
Province: Mobile No.:
Postal Code: e-mail:
Date:
Please make the cheque payable to: IMHO Canada and mail to :
The Treasurer, IMHO Canada, Unit 7 - 5637 Finch Avenue East, Toronto ON M1B 2T9 IMHO Canada is a registered Non-Profit organisation in Canada REG.No. 84419 1494 www.theimho.org