Name of Primary Account holder *
Telephone number *
Mobile phone *
Address *
City *
Province *
Postal Code *
Email *
Church family number

Payment Amount *
Payment frequency * ---Weekly-hebdomadaireBiweekly-2 semainesMonthly-Mensuel
Start Date *

To cancel your monthly payments, please send an email to apa@alsayde.org or contact the church at 514-858-7004 extension 201.

*********************** If this is a joint account, information is required on secondary account member *******************

Name of Secondary Account holder
Telephone number
Mobile phone
Address
City
Province
Postal Code

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Automatic direct debit: Complete only if you wish to settle your payment by direct debit from your bank account.

Financial Institution Name (bank name)
Financial Institution Address

Transit
Bank Number
Account Number

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Credit Card: Complete only if you wish to settle your payment through your credit card.

Credit Card Type ---VisaMastercardAmerican Express

Name of Credit Card holder
Credit Card number
Expiry date
Validation Number (CVE)
Billing Address
City
Province
Postal Code

As the account holder(s), I authorize (we authorize) the Orthodox Church and my (our) financial institution to debit my (our) account from the branch specified above or to charge it to my credit card to automatically pay the amount specified at the dates specified, in accordance with the terms of the agreement between me (us) and the church, until written notice to the contrary is served by me (us) to the church. Administrative fees are charged to my account for returned or declined payments. An amount may be charged to my credit card account or a direct debit from my (our) account may be made within 2 days of the end of the specified period. The church will try, as much as possible, to keep the same date every period, however, unforeseen circumstances may force it to change the date for a given period. I will notify (we will notify) the Church in writing of any changes to banking or credit card information or the cancellation of this authorization before the date of the next direct debit. I understand (we understand) that by submitting this authorization to the Church, I am submitting it (we are submitting it) also to the financial institution indicated above.

Saint Mary’s Antiochian Orthodox Church reserves the right to terminate my registration to the program at any time. I acknowledge (we acknowledge) having read this authorization and the conditions attached to it. I consent (we consent) that by clicking on the "I agree" checkbox below I (we) hereby certify my (our) acceptance of this agreement.

I agree to the pre-authorized payment (primary account holder)
I agree to the pre-authorized payment (secondary account holder)

(If you have a joint account, the acceptance of the 2 subscribers is required)