Pre-Authorized Payment Application

I/we authorize Alliance Metering Solutions (AMS), and the financial institution designated (or any other financial institution I/we may authorize at any time), to begin deductions for payment of all charges arising under my/our AMS account(s) through this Pre-Authorized Payment Application. Regular payments for the full amount of services delivered will be debited to my/our account(s) based on the due date of regular billings.

AMS will provide written notice of the amount and timing of each regular debit. AMS will obtain my/our authorization for any other one- time or sporadic debits. This authority is to remain in effect until AMS has received written notification from me/us of its change or termination. This notification must be received at least 10 business days before the next debit is scheduled at the address provided below.

I/We may obtain a sample cancellation form, or more information on my/our right to cancel a PAD agreement at my/our financial institution or by visiting www.cdnpay.ca. AMS may not assign this authorization, whether directly or indirectly, by operation of law, change of control or otherwise, without providing at least 10 days prior written notice to me/us. I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/We have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD agreement.

To obtain a form for a Reimbursement Claim, or for more information on my/our recourse rights, I/We may contact my/our financial institution or visit www.cdnpay.ca

Pre-Authorized Payment Plan Application Form

Please complete this form to set up Pre-Authorized Payment for your account.

Account Information
Alliance Metering Solutions Account Number*

Please enter your account number
Name on AMS Bill*
First Last
Service Address*
Street Address City Province Postal Code
Phone*
Email Address*
Banking Information
Name of Financial Institution (FI)*
Account Number*
Transit Number*

(branch: five digits) – (institution: three digits) e.g. 12345-123
Name on Cheque
First Last
Account Holder Signature*
Date*
MM slash DD slash YYYY
Joint Account Holder Signature
If this is a joint account, both parties must sign
Date
MM slash DD slash YYYY
Void Cheque*
Accepted file types: jpg, png, pdf, , Max. file size: 8 MB.
Please enclose a copy of a cheque marked ‘VOID.’ The cheque must be from the same account outlined above.
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Alliance Metering Solutions Inc. uses the information we collect on this form to facilitate pre-authorized payment for services.
We are committed to protecting the privacy of your personal information and we have developed policies and procedures in compliance with the Personal Information Protection and Electronic Documents Act.

Pre-Authorized Payment Application

Pre-Authorized Payment Plan Application Form

Account Information

Banking Information

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