Required fields are marked with asterisks (*)

Northern Maple Utilities Inc. Pre-Authorized Payment Form:

Water/Sewer Account # (If known):

Property Address:

Name(s):

Phone #:

Email:

Effective Date:

Frequency of Withdrawal:

15th of EVERY OTHER MONTH (exact amount of bimonthly bill)

15th of EVERY MONTH (amount is fixed average)

BANKING INFORMATION:

Financial Institution Number

Branch/Transit Number

Account Number

Void Cheque or Direct Deposit Form:

Browse…

Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Agreement Details:

I/we authorize Northern Maple Utilities Inc. (NMU) and the financial institution designated (or any other financial institution I/we may authorize at any time) to begin deductions as per my/our instructions for regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/ our NMU Water/Sewer account(s). Regular payments for the full amount of services delivery will be debited to my/our specified account on the date indicated. NMU will provide 10 days written notice of the amount of each regular debit. NMU will obtain my/our authorization for any other one-time or sporadic debits. This authority is to remain in effect until NMU has received written notification from me/us of its change or termination. This notification must be received at least 10 business days before the next debit is scheduled at the address provided below. I/We may obtain a sample cancellation for, or more information on my/our right to cancel a PAD agreement at my/our financial institution or by visiting www.cdnpay.ca.

Signature:

Clear

Date: