Accurate Pre-Authorized Payment Form

PRE-AUTHORIZED PAYMENT FORM

Please print this form

	YES !	I want to enjoy the convienience of your Pre-Authorized Payment Plan. I prefer the Pre-Authorized Payment plan. Equal Payment with Pre-Authorized Payment Plan.

	Customer's Name ______________________________________________________________________________

	Address ______________________________________________________________________________________

	City ________________________ Postal Code ______________ Accurate Number _______________________

	Please Note: Your first payment will include all amounts outstanding on your account.

	I/We hereby authorize:	________________________________________________ Name of Financial Institution		_______________________ Account Number

	____________________________________________ Branch Address		______________ City		___________ Province

	...to debit my/our account indicated above for all payments to Accurate Lock, Safe & Alarm.
	I/We authorize Accurate to treat each payment as if I/We had personally issued a cheque and to debit My/Our
	account for the amount due.
	I/We agree to the terms and conditions on this authorization.

_____________________
Date(day/month/year)

________________________________
Signature

Please note: For a joint account, all depositors must sign if more than one signature is required on cheques issued
against the account.For varification purposes, please enclose one of your cheques marked "VOID." include completed
form with your Accurate bill payment.
Accurate Lock, Safe & Alarm, 439 Sixth Street, New Westminster, B.C. V3L 3B1

PLEASE READ TERMS AND CONDITIONS BELOW

TERMS AND CONDITIONS OF AUTHORIZATION TO ACCURATE

1. The customer understands that this Pre -    Authorized Payment Plan is for the    convenience of the customer.
2. Accurate relies on the representation    constituted by thisauthorization that the    customer's bank account is, and shall be,    during the currency of this authorization, in    good standing with sufficient funds to cover    such pre-authorized cheques as they    become due and payable.
3. The customer's pre-authorized payment will    be withdrawn each month/every second    month, depending on the agreement, to    cover payment(s) due on the customer's    account.

4. If, on periodic review, adjustments to the Equal Payment Plan installment amount are considered necessary, these will be made only after adequate notice has been give to the customer.
5. This authorization may be terminated at any time by the customer or Accurate. Upon such termination,any balance due thereafter shall be payable directly to Accurate. If a credit balance exists on the customer's account, it will be applied to the account or refunded on request.
For more information on Accurate's convenient billing and payment options, please contact Accurate at:
(604) 659-2914

www.accuratesecurity.com

Your Security is Our Business

Accurate Lock, Safe & Alarm Co.