Par Authorization Form

PAR AUTHORIZATION FORM

FOR USE BY PAR ADMINISTRATOR

For registration of new PAR donors
orFor banking changes for existing donors

_______________________________________________________________________
PAR congregational number: ____________________________________ 
Church PAR administrator:______________________________________ 
Phone number: _______________________________________________
E-mail: _____________________________________________________

____________________________________________________________
Donortname__________________________________________________________________________________
Address:______________________________________________________________________________________
City: ___________________________Province: ________Postal code: _______________
E-mail___________________

Envelope# _____________________ Gift amount $ ______________ 
Name of local church: _________________________________________________________________
Address: ______________________________________________________________________ 

This gift to the above church is to benefit

Local church: $____________________Mission & Service: $ ___________________
Other: $ _______________________

_________________________________________________________________
Option 1: Pre-authorized debit

Please attach a VOID cheque.

I/We request/authorize The United Church of Canada to debit my/our account on the 20th of every month, 
starting the 20th _____________________ of, 20______. I/we also recognize and agree to the following:

I/we may change the amount of my contribution at any time by contacting our church PAR contact.

I/we have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAR agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca.

I/we waive my right to receive pre-notification of the amount of pre-authorized remittance (PAR) and agree that I do not require advance notice of the amount of PAR before the debit is processed.

Signed: ____________________________________________________________ Dated:________________________________

_________________________________________________________________
Option 2: Visa/MasterCard/American Express

Please note that a 2–3% service charge reduces the total of your donation to your congregation.

Card number: _________________________________________________________Expiry: ______ ______ MM YY

Name on card: __________________________________________________________________________________ Signed: ____________________________________________________________Dated: ______________________

Thank you for your generosity.

The use, retention, and disclosure of personal information collected from this form is done in compliance with privacy legislation 

and adheres to the principles of the Personal Information Protection and Electronic Documents Act (S.C. 2000, c.5).

The United Church of Canada Attn: PAR • 3250 Bloor St. West, Suite 200, Toronto, ON M8X 2Y4 

1-800-268-3781, ext. 3152/3050 • fax: 416-231-3103 • par@united-church.ca