Pre-authorized Payment Authorization
Name (s)
_____________________________________________________
Address
_____________________________________________________
Phone
_____________________________________________________
I
(we) authorize Generation-to-Generation Society to process a debit, in paper
electronic or other
Form in the amount of $
_______________ on
my (our) account once a month on the
_________ First day of the month
______________ Fifteenth day of the month (please check one)
Beginning on
________________________
Date
I
(we) acknowledge that I (we) have read and understood all of the provisions
contained in the terms
And
conditions of the pre-authorized payment authorization and that I (we) have
received a copy
Signature
________________________________
date
_______________________
Signature
________________________________
date
_______________________
(Mail this bottom half of
the form with your void cheque to the Generation-to-Generation
Society