Common Contracts
2 similar Pre-Authorized Payment Agreement contracts
Pre-Authorized Payment AgreementPre-Authorized Payment Agreement • October 22nd, 2018
Main Contact First Name Last Name Birthdate (DD/MM/YY) Gender (Circle) Male / Female / X Not Specified Residency Information Street Address City Postal Code Home Telephone Cellular Telephone Business Telephone Email Address Family Information (Family/Group Memberships Only) Name (Incl. last if different from above) Gender Birthdate (DD/MM/YY) 1. 2. 3. 4. 5. Emergency Contact Information Full Name Relationship Phone Number Payment Authorization Account Holder First Name Account Holder Last Name Account Holder Address (If different from above) Payment Type: Visa Mastercard American Express Bank Account (Attach Account Info/Void Cheque)Last 4 Digits of Card: Expiry: / Payment Date: 1st of the month 15th of the month Monthly Payment Amount $ GST (if applicable) $ Total $
Pre-Authorized Payment AgreementPre-Authorized Payment Agreement • October 22nd, 2018
Main Contact First Name Last Name Birthdate (DD/MM/YY) Gender (Circle) Male / Female / X Not Specified Residency Information Street Address City Postal Code Home Telephone Cellular Telephone Business Telephone Email Address Family Information (Family/Group Memberships Only) Name (Incl. last if different from above) Gender Birthdate (DD/MM/YY) 1. 2. 3. 4. 5. Emergency Contact Information Full Name Relationship Phone Number Payment Authorization Account Holder First Name Account Holder Last Name Account Holder Address (If different from above) Payment Type: Visa Mastercard American Express Bank Account (Attach Account Info/Void Cheque)Last 4 Digits of Card: Expiry: / Payment Date: 1st of the month 15th of the month Monthly Payment Amount $ GST (if applicable) $ Total $
