Letter of Authorization for Saving You Services Telephone Services
Contact/Account Information
Name (Mr/Mrs/Ms, 1st, Middle Initial(s), Last:_________________________________________________________________________________________
Phone:_______________________________ Fax:__________________________________ E-mail:____________________________________________
Mailing Address:_______________________________________________________________________________________________________________
City: _______________________________________________________________ Province:_______________ Postal Code:________________________
Authorized Contact Name(s) (who can we speak to & do they have authority to make changes (Yes or No beside their name):________________________________
____________________________________________________________________________________________________________________________
Referred By (name & Phone#):_____________________________________________________________________________________________________
Payment/Credit Information (Fill in preferred Pre-Authorized Payment method & See AGREEMENT below for details)
1.Credit Card:Direct Dial, 8XX Number, & Flat Rate accounts are debited upon billing
Visa/Mastercard #:____________________________________________________ Exp. Date:_________________________ Security Code:____________
Name exactly as on Card:_________________________________________________________________________________________________________
2. Bank Account: Flat Rate is Debited on the 1st or 15th (choose one)
Direct Dial &/or 8XX is Debited: Last business day of each month after invoice issued
Returned Payments are debited within 2 business days of return and/or until recovered
Name of Bank:___________________________________________________________ Location:______________________________________________
Account number:________________________________________________ Transit number:_____________________ Bank Code:___________________
Name(s) on Account:______________________________________________________________________________ # of Signatures Required:_________
Outgoing LoNG DISTANCE &/or Toll free calling (Fill In ONE(s) REQUIRED)
1. Direct Dialed Long Distance (no access code required): Billed cents per minute and No monthly fee when minimum $20/month spending between acct(s) or a
Flat rate service is in place with us. $5.00/month when minimums not met or no Flat rate service with us.
Number(s) to be activated: ______________________________________________________________________________________________________
Local Service Provider(s):_______________________________________________________________________________________________________
Continental North America: $0.039 U.K.: $0.039 Country & Rate:_______________________________ Country & Rate:______________________________
Country & Rate:________________________ Country & Rate:_______________________________ Country & Rate:______________________________
2. 800/866/877/888 Number: Billed @ 5 cents per minute/ $2.95, $5.00, or $8.00 monthly fee (see terms)
Existing Number(s) to be transferred: #1:__________________________________________________ #2:___________________________________________
New Number(s) Requested :#1:______________________________________________ #2:_________________________________________________________
(When #’s of your choice are not available others are assigned)
Terminating #(s) (phone # 8XX # will ring off ):#1:________________________________________ #2:______________________________________________
Monthly fee(s): #1:________________________________________ #2:______________________________________________
Directory Assist: Yes/No
Access Area (circle one or more): Ontario / Canada / USA
3. Flat Rate Service Choose A, B, C (Monthly Fee applies these services and are due in advance of service / Overages on timed rates are billed at $0.04/minute
and are due by the chosen payment method on the last day of the month following their billing)
Number(s) to be activated:_______________________________________________________________________________________________________
A. # of minutes required for Ontario/Canada/ USA/North American (circle one/all):____________________________________________________________
B. Hamilton Local Calling Only:________________________________________ C. Other (please specify):_______________________________________
___________________________________________________________________________________________________________________________
Agreement
By submitting/returning this application, I/We confirm that I/We have read, understand, and agree to all of the terms and conditions of the Telesave service agreement
attached (by fax and/or mail), and/or posted at www.telesavecanada.ca. I/We further authorize Telesave to:
1) …make inquiries into the banking and business/trade references that I have supplied.
2) …activate the above requested services.
3) …debit my/our credit card and/or bank account for my services on the appropriate dates. (All Types of Returned/Declined payments are process automatically, along with
the return item fees, 2 days later and/or until recovered)
a) I/we authorize Telesave and the financial institution designated (or any other financial institution I/We may authorize at any time) to begin deductions as per my/our
instructions for monthly regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our Telesave account(s).
Regular monthly payments for the full amount of services delivered will be debited to my/our specified account on the above date(s) each month.
b) This authorization is to remain in effect until Telesave has received written notification from me/us of its change or termination. This notification must be received at
least fifteen (15) business days before the next debit is scheduled at the address provided above. 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.
c) Telesave may not assign this authorization, whether directly or indirectly, by operation of law, change or control or otherwise, without providing at least 10 days prior
written notice to me/us. I have certain recourse rights if any debit does not comply 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.
SIGNATURES: 2ND or More SIGNATURE(S) ONLY REQUIRED IF MORE THAN ONE SIGNER IS REQUIRED BY FINANCIAL INSTITUTION(S) AGREEMENTS. WHERE/WHEN
APPLICABLE, FAILURE TO PROVIDE ALL SIGNATURES IS PUNISHABLE BY LAW.
Signature:___________________________________________________________________________ Date:____________________________________________________
Print Name/Title: _____________________________________________________________________________________________________________________________
Signature:___________________________________________________________________________ Date:____________________________________________________
Print Name/Title: _____________________________________________________________________________________________________________________________
Contact/Account Information
Name (Mr/Mrs/Ms, 1st, Middle Initial(s), Last:_________________________________________________________________________________________
Phone:_______________________________ Fax:__________________________________ E-mail:____________________________________________
Mailing Address:_______________________________________________________________________________________________________________
City: _______________________________________________________________ Province:_______________ Postal Code:________________________
Authorized Contact Name(s) (who can we speak to & do they have authority to make changes (Yes or No beside their name):________________________________
____________________________________________________________________________________________________________________________
Referred By (name & Phone#):_____________________________________________________________________________________________________
Payment/Credit Information (Fill in preferred Pre-Authorized Payment method & See AGREEMENT below for details)
1.Credit Card:Direct Dial, 8XX Number, & Flat Rate accounts are debited upon billing
Visa/Mastercard #:____________________________________________________ Exp. Date:_________________________ Security Code:____________
Name exactly as on Card:_________________________________________________________________________________________________________
2. Bank Account: Flat Rate is Debited on the 1st or 15th (choose one)
Direct Dial &/or 8XX is Debited: Last business day of each month after invoice issued
Returned Payments are debited within 2 business days of return and/or until recovered
Name of Bank:___________________________________________________________ Location:______________________________________________
Account number:________________________________________________ Transit number:_____________________ Bank Code:___________________
Name(s) on Account:______________________________________________________________________________ # of Signatures Required:_________
Outgoing LoNG DISTANCE &/or Toll free calling (Fill In ONE(s) REQUIRED)
1. Direct Dialed Long Distance (no access code required): Billed cents per minute and No monthly fee when minimum $20/month spending between acct(s) or a
Flat rate service is in place with us. $5.00/month when minimums not met or no Flat rate service with us.
Number(s) to be activated: ______________________________________________________________________________________________________
Local Service Provider(s):_______________________________________________________________________________________________________
Continental North America: $0.039 U.K.: $0.039 Country & Rate:_______________________________ Country & Rate:______________________________
Country & Rate:________________________ Country & Rate:_______________________________ Country & Rate:______________________________
2. 800/866/877/888 Number: Billed @ 5 cents per minute/ $2.95, $5.00, or $8.00 monthly fee (see terms)
Existing Number(s) to be transferred: #1:__________________________________________________ #2:___________________________________________
New Number(s) Requested :#1:______________________________________________ #2:_________________________________________________________
(When #’s of your choice are not available others are assigned)
Terminating #(s) (phone # 8XX # will ring off ):#1:________________________________________ #2:______________________________________________
Monthly fee(s): #1:________________________________________ #2:______________________________________________
Directory Assist: Yes/No
Access Area (circle one or more): Ontario / Canada / USA
3. Flat Rate Service Choose A, B, C (Monthly Fee applies these services and are due in advance of service / Overages on timed rates are billed at $0.04/minute
and are due by the chosen payment method on the last day of the month following their billing)
Number(s) to be activated:_______________________________________________________________________________________________________
A. # of minutes required for Ontario/Canada/ USA/North American (circle one/all):____________________________________________________________
B. Hamilton Local Calling Only:________________________________________ C. Other (please specify):_______________________________________
___________________________________________________________________________________________________________________________
Agreement
By submitting/returning this application, I/We confirm that I/We have read, understand, and agree to all of the terms and conditions of the Telesave service agreement
attached (by fax and/or mail), and/or posted at www.telesavecanada.ca. I/We further authorize Telesave to:
1) …make inquiries into the banking and business/trade references that I have supplied.
2) …activate the above requested services.
3) …debit my/our credit card and/or bank account for my services on the appropriate dates. (All Types of Returned/Declined payments are process automatically, along with
the return item fees, 2 days later and/or until recovered)
a) I/we authorize Telesave and the financial institution designated (or any other financial institution I/We may authorize at any time) to begin deductions as per my/our
instructions for monthly regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our Telesave account(s).
Regular monthly payments for the full amount of services delivered will be debited to my/our specified account on the above date(s) each month.
b) This authorization is to remain in effect until Telesave has received written notification from me/us of its change or termination. This notification must be received at
least fifteen (15) business days before the next debit is scheduled at the address provided above. 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.
c) Telesave may not assign this authorization, whether directly or indirectly, by operation of law, change or control or otherwise, without providing at least 10 days prior
written notice to me/us. I have certain recourse rights if any debit does not comply 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.
SIGNATURES: 2ND or More SIGNATURE(S) ONLY REQUIRED IF MORE THAN ONE SIGNER IS REQUIRED BY FINANCIAL INSTITUTION(S) AGREEMENTS. WHERE/WHEN
APPLICABLE, FAILURE TO PROVIDE ALL SIGNATURES IS PUNISHABLE BY LAW.
Signature:___________________________________________________________________________ Date:____________________________________________________
Print Name/Title: _____________________________________________________________________________________________________________________________
Signature:___________________________________________________________________________ Date:____________________________________________________
Print Name/Title: _____________________________________________________________________________________________________________________________