Pre-Authorized Contribution/donation Service Form - The Salvation Army (Canada & Bermuda)

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The Salvation Army
Kelowna Community Church
1480 Sutherland Ave.
Canada & Bermuda
Kelowna BC V1Y 5Y5
BC Division
Tel: 250-860-2329
Fax: 250-861-3025
“Pre-Authorized Contribution/Donation” Service
Donor Name:
Mailing Address or
Contact Information:
By signing and submitting this form, you verify that you are the person(s) required to sign on the
provided account, and you authorize The Salvation Army to debit your bank account for the purpose
making a charitable contribution/donation, as outlined below. This donation is on behalf of:
□ an individual □ a business.
st
In the amout of : $__________
Processed:
Once per month on the 1
of each month
th
Once per month on the 15
of each month
st
th
Twice a month on the 1
and 15
of each month
Your have designated your contribution/donation for the following purposes:
$_____ General offering/support
$____ National Red Shield Appeal
$_____ Youth Ministries/YP Corps
$____ Partners In Mission/Self-Denial Appeal
$_____ Home Missions Appeal
$_____ Child Sponsorship Program
$_____ Other_______________________
$_____ Other_______________________
$_____ Other_______________________
(subject to confirmation of program availability)
You may cancel or modify this agreement at any time, provided you notify us in writing at least 30 days
of the next scheduled debit, by contacting us at the address or telephone number listed above.
Signature: ______________________________________________
Dated: ____________________
Signature: ______________________________________________
Dated: ____________________
(Additional signature, if required for joint accounts)
Please include a copy of your cheque marked --- VOID --- or a copy of a pre-printed deposit slip.
Statement of recourse:
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 The Salvation Army will never transfer the right to debit your account to any other
party.
André Cox
William and Catherine Booth
Susan McMillan
Larry Martin
General
Founders
Territorial Commander
Divisional Commander

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