1.   Infomation

      Date (dd/mm/yyyy) :

         Full Name :  

         Address    :  

         City           :  

Province :

Pincode :

         Telephone number    :  

                  Email :

         2.   Void Cheque

              Include a "VOID" cheque. Your authorization can not be proessed without it.

         3.   AGREEMENT (Payment)

          I/we Authorize the toronto Thiruchendur Murugan Temple to debit my/our bank account (as per the attached void cheque).

          in the amount of    $51       $75       $101   or   Others $  on my (our) account on the date   

          day of each month, beginning (Month)      (Year) 

          Note: if the 15th or 20th fals on a weekend or holiday the deduction will be taken out the following business day.

         4.   All authorized signatures required (If Join Account, all authorized are required)

Signature of account holder

Signature of joint account holder

Name(Please print)

Name(Please print)

Date(Month/Day/Year)

Date(Month/Day/Year)

I agree to the Terms & Conditions

Submit