Common Contracts
1 similar Pre-Authorized Payment Plan Agreement contracts
ContractPre-Authorized Payment Plan Agreement • October 16th, 2012
First Name: Last Name: CRPNM Registration # Address: City: PostalCode: Telephone: Email: YES I want to participate in the Pre-authorized Payment Plan I am a New EnrolleeI am already enrolled and I am reporting changes to my Banking Information I wish to add $ to my monthly payment in support of the Registered Psychiatric Nurses Foundation (RPNF) I have enclosed a VOID cheque. I understand the following conditions apply: 1. This agreement is in perpetuity;2. A request for removal from the Pre-authorized Payment Plan must be submitted to the CRPNM in writing;3. Any Pre-authorized debits that are refused by my bank will be subject to a $50.00 service fee;4. That 2 NSF occurrences during the plan period will result in cancellation of my participation in the plan;5. That it is my responsibility to promptly notify the CRPNM of any changes to my banking information. Signature: Date:
