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Pre-Authorized Payment

I/We hereby authorize Peterborough Utilities Group to draw and issue payable to Peterborough Utilities Group for payment of my/our utility account.

Account holder first name

Account holder last name

Utility account number

Account holder's email address

Address

Street number

Unit number

Street name

City

Province

Postal code

Authorization to honour payments in favour of:

To ensure accuracy please upload a copy of your void cheque or pre-authorization form from your financial institution

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Date

Signature (s)

If the deposit is waived in lieu of pre-authorized payment: I agree to pay a deposit in full if any payments are returned to Peterborough Utilities Group.

Account holder's name

Account holder's signature(s)