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2. Name*
3. Name of Joint Bank Account Holder
5. Email Address*
6. Service Address/Account Number*
8. Phone Number*
9. Cell/Alternative Number*
11. Attach a scanned cheque marked “VOID” or a bank confirmation form*
12. Start Date*
    Start Date
14. I/We authorize the Town of Slave Lake and the financial institution designated (or any other financial institution I/we may authorize at any time) to debit the bank account identified above on the 15th day of each month for the current monthly amount of my utility bill. The actual withdrawal date at my financial institution may vary slightly but I will ensure that my account has sufficient funds to cover the pre‐authorized withdrawal. In the event that two payments are missed within a calendar year this agreement will be automatically cancelled. The monthly amount will vary during the year up to a maximum of $500.00.
16. I/We  have  certain  recourse  rights  if  any  debit  does  not  comply  with  this  agreement.   For  example,  I/we  have  the  right  to  receive  reimbursement for any payment that is not authorized or is not consistent with this agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.cdnpay.ca.
18. This authority is to remain in effect until the Town of Slave Lake has received written notification from me/us of its change or termination; this notification must be received at least ten (10) days before the next debit is scheduled. I/We may obtain a sample cancellation form, or more information on my/our right to cancel this agreement at my/our financial institution or by visiting www.cdnpay.ca.  Town of Slave Lake pre‐authorized payment cancellation and change of bank forms are available online at www.slavelake.ca or through the contact information below. 
20. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
22. Electronic Signature Bank Holder
23. Electronic Signature of Joint Bank Account Holder
25. The personal information requested on this form is being collected by Municipal Operation as required by the Town of Slave Lake, under the authority of the Freedom of Information and Protection of Privacy Act (FOIP act) Section 33(c). If you have any questions  about the collection or use of your personal information, contact the Town of Slave Lake FOIP Coordinator at (780)849‐8018.
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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