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Pre-Authorized Credit Card Payments
Pre-authorized Payment is a convenient way to automatically pay your bills with your credit card.
This form provides account information and is used when arranging pre-authorized payments. Simply complete this form and submit it.
Questions?
Call us at
1-519-948-5854
Your Information
Name
*
First
Last
Please enter the name as it appears on the credit card.
Email Address
*
Phone
Please provide a phone number with area code in case we need to contact you.
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Herby Curby Account #
If known, please enter your account number.
Credit Card Information
Card Number (no spaces)
*
Expiry Date (mm/yy)
*
CSV on back of card
*
Category
*
Personal
Business
Please select whether this is for personal or business use.
Payment Frequency
Please select how often you wish to make your payment.
*
We offer either monthly or quarterly payment. Quarterly payments are are on the 1st of March, June, September and December. Your 1st payment may be pro-rated for the number of months in that period.
Monthly
Quarterly
Terms & Agreement
Terms
*
I have read and agree to the terms of this pre-authorized payment by credit card.
Signature
*
Reset signature
Signature locked. Reset to sign again
Date
*
YYYY dash MM dash DD
CAPTCHA
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