Eastlink Pre-authorized Payment Form

Eastlink Pre-authorized Payment Form
1. CUSTOMER INFORMATION
Name of Account Holder:
Daytime Telephone Number:(
)
Eastlink Account Number(s)
Type of service:
Personal
New Pre-authorized setup
Business
Make changes
Wireless
Cancel
2. Pre-authorized Bank Account Debit (copy of void cheque required)
Bank Account #:
Branch #:
(up to 5 digits) Institution #:
(3 digits)
To be set up for Pre-authorized Credit Card (Visa, MasterCard & American Express)
Please call 1-888-345-1111 or visit www.eastlink.ca My Eastlink My Account
I/we authorize my/our financial institution to debit my/our account on (or after) the due date of each invoice for all amounts owing to Eastlink.
This authorization is valid for the bank account specified above, or any other account which I/we may designate in the future in lieu of the
account specified above. I/we understand that if any payment is returned by the Bank for any reason, I/we will be responsible for NSF and/or
administration charges. I understand the first automatic withdrawal will not take place for at least 20 days from Eastlink’s receipt of this signed
agreement. Any amounts due to Eastlink prior to that effective date must be paid via a one-time payment.
I/we have certain recourse rights if any debit does not comply with this agreement. I/we have the right to receive reimbursement for any debit
that is not authorized or is not consistent with this pre-authorized agreement. I/we may cancel or update this agreement at any time by
providing written notice to the address below or by contacting Eastlink at 1-888-345-1111, Delta Cable / Coast Cable at 604-946-7676 or
Eastlink Wireless at *611 at least (30) thirty days before the next scheduled withdrawal date. As the payment amount is variable I/we
expressly agree to waive any requirement that Eastlink give pre-notification of any payment amount. I further understand that the
amount debited from my account may be different than the amount indicated on my monthly Eastlink bill as the amount debited may reflect
subsequent transactions.
I also acknowledge that my Eastlink service and pre-authorized payments are subject to Eastlink’s Terms of Service found at
www.eastlink.ca/terms.
To obtain a sample cancellation form, or to obtain more information on my/our recourse rights and right to cancel a pre-authorized agreement,
I/we may contact my financial institution or visit www.cdnpay.ca
Customer Signature:
Date:
Send this form along with a void cheque to:
Eastlink/Delta Cable/Coast Cable – Customer Payment Services:
mail: PO Box 8600, Halifax, NS B3K 5M2
Rep No. _________
Date
_________