Card Holder Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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I have read and understand the following: I may revoke my authorization at any time, subject to providing notice of 10 days. To obtain a sample cancellation form, or for more information on my 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 copy with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca. *

Yes, I understand.

By checking this box and submitting this form, you are authorizing Youth Unlimited/YFC Calgary, to debit your account stated, for a monthly donation. *

Yes - please authorize a monthly donation using the above information