Pre-Authorized Payment Form

Pre-Authorized Debit (PAD) Agreement

Customer Information

* Name

* Swan Account Number

* Street Address

* City

* Province

* Postal Code

* Email

Bank Account Information

* Account Number

* Branch Transit Number

* Financial Institution Number

* Account Type

Chequing Account Savings Account

* Financial Institution Name

* Branch Address

Pre-Authorized Debit (PAD) Details You, the Payor, authorize Swan Dust Control Ltd. to debit the bank account identified above for the
full amount of services delivered, on the 20th of every month (or the next business day).

Pre-Authorized Debit (PAD) Details

You, the Payor, authorize Swan Dust Control Ltd. to debit the bank account identified above for the full amount of services delivered, on the 20th of every month (or the next business day).

* These services are for (check one):

Business Use Personal

You, the Payor, may revoke your authorization at any time by providing at least five (5) days notice, in writing or via e-mail. 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.

* Signature of Account Holder: By checking this box, you are digitally signing the agreement on behalf of the details provided on this form. This is legally binding.

I Agree

Signature of Joint Account Holder (if applicable):

I Agree

You have certain recourse rights if any debit does not comply with this agreement. For example, you 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 your recourse rights, contact your financial institution or visit www.cdnpay.ca.