Pre-Authorized Payment Form

Please print the following form.

Last Name: ________________________ First Name: ________________________________
Call Select Account #: _______________ Telephone: ________________________________
Address: ______________________________________________________________________
City: ___________________ Province: ____________________ Postal Code: _____________
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Credit Card
I authorize Call Select to debit my credit card with the amount due shown on my monthly Call Select invoice or
statement:
VISA MasterCard AMEX Card Holder’s name: ________________________
Credit Card No: _______________________________________ Expiry Date:_____________
Card Holder’s Signature: ________________________________ Date Signed: _____________
******************************************************************************
Pre-authorized Debit (PAD) Agreement
These services are for (check one) Personal Business
I authorize Call Select to debit my bank account (attach void cheque) for the amount due shown
on my monthly Call Select invoice or statement.
Financial Institution Number: _________ Branch Transit Number: _____________________
(3-digit) (5-digit)
Account Number: ___________________ Account Holder’s Name: _____________________
Account Holder’s Signature: ______________________ Date Signed: __________________
I may revoke my authorization at any time in writing or by phone, subject to providing notice of at least ten (10)
business days. To obtain a sample cancellation form, or for more information on your right to cancel a PAD
Agreement, I may contact my financial institution or visit www.cdnpay.ca.
I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to
receive reimbursement for any debit that is not authorized or is not consistent with the PAD Agreement. To obtain
more information on my recourse rights, I may contact my financial institution or visit www.cdypay.ca.
A service charge of $50.00 will be applied to any declined credit cards or pre-authorized payment charge backs.
Mail or Fax Completed Form to: Call Select Inc, PO Box 48227, 595 Burrard St, Vancouver BC, V7X 1N8
Toll Free: 1-866-638-1001 Fax: 1-866-638-2002 Email: cs@callselect.ca

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Source: http://docphy.com/business-industry/personal-finance/credit-cards/pre-authorized-payment-form.html