Pre-Authorized Debit Form - Pacific Quorum Vancouver Island Property Management

1. Customer Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number*

2. Bank Account Information

Account Number*

Branch Transit Number*

Financial Institution Number*

Account Type*

Checking Account
Saving Account

Name (Financial Institution)*

Address (Financial Institution)*

3. Pre-Authorized Debit (PAD) Details

You, the Payor, authorize Randall North Real Estate Services Inc. to debit the bank account identified above for regular monthly rental fees. We, the Payee, Randall North Real Estate Services Inc. will provide you, the Payor, 10 days written notice of the amount of each regular debit, unless such notification is waived in the section below. Pre-notification will always be given to you when the regular monthly rental fees change. Regular monthly rental fees will be debited on the first day of the month or on the next business day.

Pre-Notification Advice Waiver*

By initialing above you, the Payor, agree that the standard pro-notification required 10 days prior to each debit of the regular monthly rental fees is hereby waived, Pro-notification will only be required 10 days before the first debit of the regular monthly rental fees after an amount change and/or in the event of one-time payments.

These services are for:*

Personal use
Business use

You, the Payor, may revoke your authorization at any time (insert process e.g. in writing or by phone) subject to providing notice of (insert time period, not to exceed 30 days). To obtain a sample cancellation form or for more Information on your right to cancel a PAD Agreement, contact your financial institution or visit www.cdnpay.ca.

Account Holder Information

Signature of Account Holder*

Name*

Date*

Joint Account Holder Information(if applicable)

Signature of Account Holder

Name

Date

You have certain recourse rights if any debit does not comply with this agreement. For example, you 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 your recourse rights, contact your financial institution or visit www.cdnpav.ca. When the form is complete, please mail or fax to: Randall North Real Estate Services Inc. PO BOX 53531 Victoria, BC, V8X5K2. Tel: (250)658-8060, Fax: (250)658-8067.