PAR Autorisation Form



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

PAR congregational number: ___________________________________ Church PAR administrator:______________________________________ Phone number: ______________________________________________ E-mail: _____________________________________________________

Donor name: _______________________________________________________________________________________________

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:

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

ƒ 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

ƒ 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 •