20 Floral Parkway, Concord, Ontario L4K 4R1
Telephone: 416.736.0630 Fax: 416.736.4923 email@example.com www.pemi.com
PRE-AUTHORIZED CHEQUING PLAN FORM
With Pre-Authorized Chequing from Provident Energy Management Inc., your Bill is automatically paid
from your chequing account. You will continue to receive a regular invoice and we simply deduct the
amount owing on the due date of the invoice. Once set up on Pre-Authorized Chequing your invoice will
state “Pre-Authorized Payment Plan Do Not Pay”.
Please note the following to ensure proper set up:
include a “voided” cheque
DO NOT USE A LINE OF CREDIT ACCOUNT
Any outstanding amounts must be paid in full before the pre-authorized payment plan can be
applied to your account
Fill in ALL sections to ensure proper set up on Pre-Authorized Payment Plan.
Service Location: _________________________________________________
Customer Number # ________ ______
(If this form is completed before your first invoice, you will not have a customer number.)
Day Time Telephone # ______________ _______
Yes � I have enclosed a “Voided” Cheque and hereby authorize my financial institution to debit my
account in the name of Provident Energy Management Inc.
Dated this _______ day of _____________________, 20_____.
For joint accounts, all account holders must sign if more than one signature is required on cheques
issued or drawn against the account.
Print Name of Account Holder Print Name of Account Holder
Signature of Account Holder Signature of Account Holder
Please note if a payment is dishonored by your bank for any reason, we have the right to terminate
your participation in the Plan. A service fee will be applied to your account in response to the
Upon termination, ANY AMOUNT DUE shall be paid directly to Provident Energy Management Inc.
Cancellation of pre-authorized debit does not constitute cancellation of service by Provident Energy
Management Inc. and the customer shall be liable for any past, present or future amounts owing.
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 pre-authorized debit agreement. To obtain more information on your recourse rights, contact
your financial institution or visit www.cdnpay.ca
Please email, fax or mail this form to: Provident Energy Management Inc.