PRE-AUTHORIZED DEBIT (PAD)
and/or PLEDGE FORM


ABOUT SSL
CERTIFICATES

Contact Information:

Title:
First Name:
Last Name:
Spouse's First Name:
Spouse's Last Name:
Home Phone:
Business Phone:
ext.
Mailing Address:
 
Town:
Province:
Postal Code:
E-mail Address:

PRE-AUTHORIZED DEBIT

(complete all information in order that the Meaford Hospital Foundation may take your donation directly from your bank account)

Installments:One-Time
Monthly
Quarterly
Annual
First Installment will be paid on: (mm/dd/yy)
First Installment Amount:
Last Installment will be paid on: (mm/dd/yy)
Last Installment Amount:

Banking Information:

Please attach a void cheque to this form and mail to Meaford Hospital Foundation (229 Nelson St. West, Meaford ON N4L 1A3).
Account Type:
Bank #:
Account #:
Transit #:
Name of Bank or Trust Company:
Address of Bank or Trust Company:
 
Town of Bank or Trust Company:
Province of Bank or Trust Company:
Postal Code of Bank or Trust Company:
Phone of Bank or Trust Company:

I/we that the Meaford Hospital Foundation may process charges to my/our account for the purposes of gifts or donations to the Meaford Hospital Foundation.

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 debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on my/our recourse rights, I/We may contact our financial institution or visit www.cdnpay.ca.

I/We may revoke my authorization at any time, subject to providing notice of (Payee to insert period – not to exceed 30 days). To obtain a sample cancellation form, or for more information on my right to cancel a PAD Agreement, I may contact my financial institution or visit www.cdnpay.ca.

TYPE OF DONATION:

One-Time
In Memory Of
In Honour Of
In Memory/Honour Of:
  
Send Acknowledgement To: 
First Name:
Last Name:
Mailing Address:
 
Town:
Province:
Postal Code:

RECOGNITION:

All gifts to the Meaford Hospital Foundation are greatly appreciated. Every donor is recognized in accordance with our Donor Recognition Policy. Please complete the following recognization information For the purpose of recognition, I/we would like our name(s) to appear in the annual

Donor listing and the Donor Video Display as follows:

Do you wish your donation to remain confidential: YesNo

All donations are tax deductible and will be receipted upon payment. Charitable Reg. No. 11903 6408 RR0001 The Meaford Hospital Foundation adheres to high standards governing ethics, privacy and financial management. We do not rent, trade or sell our mailing lists. Personal information, provided by you, is used solely for the purpose for which it was intended and is maintained in a secure manner. You may contact us to remove your name from our mailing list or files.

All donations are tax deductible. Receipts will be issued, upon payment, for all donations $10.00 and over. Charitable Reg. No. 11903 6408 RR0001

The Meaford Hospital Foundation adheres to high standards governing ethics, privacy and financial management. We do not rent, trade or sell our mailing lists. Personal information, provided by you, is used solely for the purpose for which it was intended and is maintained in a secure manner. You may contact us to remove your name from our mailing list or files.

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