Personal Banking | ATB Financial



ATB Direct Deposit/Debit Form

|Customer/Account Information |

|Name: |      | |      | |      |

| |First | |Middle | |Last |

|Address: |      | |      | |      | |      | |        |

| |Unit/ Apt # | |Street | | City | |Province | |Postal Code |

|Telephone Numbers: |(   )     -      | |(   )     -      | |(   )     -      |

| |Home | |Mobile | |Alternate |

| |

| |Transit |Institution |Account # |

|ATB Financial: |

|For the purpose of: | Direct Deposit | Direct Debit |

| |

|Company Name: |      |

| |

|I, the undersigned: |

|Certify that the information on this form is true and correct |

|Consent to the exchange of this information for the purpose of an electronic funds transfer between ATB Financial and the company/creditor named above |

|Understand that the use, disclosure and storage of this form remains the responsibility of myself and/or the direct creditor/debitor. |

| |

| | |

| |Customer Signature |

| |

| | |

|Stamp Here (if applicable) |

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™ Trademarks of Alberta Treasury Branches.

Page 1 of 1

Form 20914 (07/14)

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