Pioneer Memorial United Church

PAR Authorization Form
Text Box: PAR AUTHORIZATION CARD I hereby request and authorize: Pioneer Memorial United Church to cause a debit to be drawn on my account each month in the amount of $_________________ as a contribution by me to Pioneer Memorial United Church. Contributor’s Name ___________________________________________________________________________________ Distribution:     Local _______________        M&S _______________                Other ____________________________________ Financial Institution/Credit Card Information ______________________________      _________________________________ TO ENSURE ACCURACY A SAMPLE CHEQUE, MARKED “VOID”, MUST ACCOMPANY THIS CARD.       _______________________________________________________________        ____________________________                                             Signature of Contributor                                                                                  Date This Authorization may be changed by the donor at any time. The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5). Church Sketch

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