Al-Ihsan Pre-Authorization Debit Page - Al-Ihsan Educational Foundation

Pre-Authorization Debit Payment Form

Step 1 of 5

Name(Required)

First Last

Date of Birth(Required)

Email(Required)

Home Phone

Cell Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

What is the purpose of your payment?(Required)

Please specify other!(Required)

What course are you paying for?(Required)

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This payment is for(Required)

If payment is for someone else, please provide details(Required)

Payment Amount(Required)

Payment Frequency(Required)

One-time payment

Monthly Recurring Payment

Pre-authorized Debit Payment(Required)

Please note that you will not be charged anything at this time. The information provided will be submitted to Al-Ihsan's Financial Department through a secure connection, which will then be processed at a later time.

Payments will be charged on approximately the 15th of every month. Exact dates may vary based on weekends/holidays.

I understand!

I will provide my bank information via(Required)

Please upload your void cheque(Required)

Max. file size: 64 MB.

Financial Institution Number(Required)

Transit Number(Required)

Account Number(Required)

Authorization(Required)

Please read
I understand that the funds will be deposited directly into the Al-Ihsan Educational Foundation’s account. I may revoke my authorization at any time in writing or by phone, subject to providing notice of at least ten (10) business days. I have the right to receive reimbursement for any debit that is not authorized or is not consistent with the PAD or Credit Card Agreement. Al-Ihsan Educational Foundation will not share my credit card or bank information with any third party whatsoever, aside for the bank through which the payments will be made. To obtain more information, I may contact my financial institution or visit www.cdypay.ca.

I have read and understood the above

Signature - Enter full name(Required)

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Date Signed(Required)

Pre-Authorization Debit Payment Form

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