This form serves the same purpose as a “VOID” cheque.

Confirmation of Account Information

This form serves the same purpose as a "VOID" cheque.

To:

Company/Vendor

Please accept this as confirmation of Account Information regarding my:

Pre-Authorized Credit

Account/Policy Number

Pre-Authorized Debit

Business Name: (if applicable)

Name/Account Signer Name:

First Name

Address:

First Name

Middle Initial Middle Initial

Last Name Last Name

City

Province

Postal Code

Account #:

Branch No. (5 digits)

Account No. (11 or 12 digits)

Reset

Print

Signature/Authorized Account Signer:

Signature/Authorized Account Signer:

809

Institution No.

Branch Number

Account Number

Date: Date:

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