PAYMENT AUTHORIZATION

CUSTOMER INFORMATION

PersonalBusiness

BANK ACCOUNT/CREDIT CARD INFORMATION

ChequingSavings

Please attach a void cheque.

Credit card

(Located on back of card)

PAYMENT OPTIONS/PRE-AUTHORIZED DEBIT (PAD) AGREEMENT

PRE-AUTHORIZED DEBIT (PAD) – EQUAL PAYMENT PLAN (SEPTEMBER TO JUNE)

I/We the Payor authorize Dodsley Propane to debit the bank account or credit card number identified above for monthly recurring payments (and/or one time payments from time to time) in the following amount on the 20th of the month (or the next business day). This amount is subject to change with each new season with 30 days written notice to the Payor. The monthly payment will be based on your projected annual propane use.

(OR)

PRE-AUTHORIZED DEBIT (PAD) – FULL BALANCE CUSTOMERS

I/We the Payor authorize Dodsley Propane to debit the bank account or credit card number identified above for monthly payments (and/or one time payments from time to time) for all charges applied to my Dodsley Propane account. Payments to be processed on the due date of the 20th of the month following charges (or the next business day).

AUTHORIZATION

I/We the Payor may revoke authorization at any time by telephone with written confirmation subject to providing notice of 10 business days prior to next withdrawal. To obtain a sample cancellation form, or for more information on your right to cancel a PAD Agreement, contact your financial institution or visit www.cdnpay.ca.

By submitting you agree to the terms and agreements above.