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Pre Authorized Payment Plan Banking Information Change

2. Property Address*

4. Name*

5. Name of Joint Bank Account Holder

7. Email Address*

8. Phone Number*

10. Attach a scanned cheque marked “VOID” or a bank confirmation form*

11. Change Effective Start Date*
    Change Effective Start Date

    Change Effective Start Date

13. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
15. Electronic Signature Bank Holder *

16. Electronic Signature of Joint Bank Account Holder

18. The personal information requested on this form is being collected by Municipal Operation as required by the Town of Slave Lake, under the authority of the Freedom of Information and Protection of Privacy Act (FOIP act) Section 33(c). If you have any questions  about the collection or use of your personal information, contact the Town of Slave Lake at (780) 849‐8000

    The personal information requested on this form is being collected by Municipal Operation as required by the Town of Slave Lake, under the authority of the Freedom of Information and Protection of Privacy Act (FOIP act) Section 33(c). If you have any questions  about the collection or use of your personal information, contact the Town of Slave Lake at (780) 849‐8000

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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

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