Name on NCF Account ______________________________ NCF Account ID _________
Signed ______________________ Date ______________________
Signature of Parent or Guardian if under 18 _____________________
Street Address __________________________________________
City/Prov/Postal Code ____________________________________
I/We (for joint account) Name(s)
authorize the National Capital FreeNet Incorporated to debit my/our Bank Account
for the amount of $ ________ on or about the 20th of each month starting
Month:_______ Year:_______ as per the Terms and Conditions below.
Name of Financial Institution ______________________________________________
All numbers from the bottom of your cheque:
or include a cheque marked "Void" with this form.
Signature ____________________________________ Date _______________
* All persons must sign if more than one signature is required on cheques issued against the account.
I/We will notify National Capital FreeNet Incorporated in
writing of any changes in the account information or termination
of this authorization at least thirty (30) days prior to the next
MY/OUR financial institution will treat each debit as if I/We had personally issued a written direction authorizing National Capital FreeNet Incorporated to debit the amount specified to my/our account and need not verify that payments are drawn in accordance with this authorization.
I/We understand that any debits charged to my/our account will be reimbursed if:
(a) this debit was not drawn in accordance with this authorization;
(b) this authorization has been terminated; or
(c) the debit was posted to the wrong account due to invalid/incorrect account information supplied by National Capital FreeNet Incorporated, by giving notice in writing to my/our branch of account within ninety (90) days of the debit to my/our account.
I/We acknowledge that delivery of this authorization to National Capital FreeNet Incorporated constitutes delivery to my financial institution.
I/We warrant that all persons whose signatures are required to sign upon this account have signed this authorization.