PAD Change Notice (Pre-auth Debit)

Name*
I/We, ___________ ___________ wish to cancel my/our authorization to issue Personal/Business pre-authorized debit:
First Name Last Name
Email
Second Name (if applicable)
I/We, ___________ ___________ wish to cancel my/our authorization to issue Personal/Business pre-authorized debit:
First Name Last Name
Email
Amount:*
I wish to cancel my/our authorization to issue Personal/Business pre-authorized debit in the amount of:
Please enter a number greater than or equal to 0.
Date*
I wish to cancel my/our authorization to issue Personal/Business pre-authorized debit on the effective date of:
MM slash DD slash YYYY
Consent*
I/We acknowledge that
this cancellation does not terminate any other obligation that I/We may have
with the Payee.
I agree
Consent*
I agree to the privacy policy stated below.
The City of Corner Brook uses this web form to collect your information in order to better administer programs and services that citizens use and rely on. The City of Corner Brook committed to protecting the privacy of individuals who chose to utilize these services.
This information is collected in compliance with the Access to Information and Protection of Privacy Act, 2015 (ATIPPA, 2015) and will only be used by authorized staff to fulfill the purpose for which it was originally collected, or for a use consistent with that purpose unless you expressly consent otherwise. This information is not disclosed to other public bodies or individuals except as authorized by ATIPPA, 2015.