Payor Pre-Authorized Debit Agreement

SCHEDULE "B"

PAYOR'S PAD AGREEMENT

Personal Pre-Authorized Debit Plan

Authorization of the Payor to the Payee to Direct Debit an Account

December 2008

Instructions:

Please complete all sections in order to instruct your financial institution to make payments directly from your account
Please sign the Terms and Conditions
If you have any questions, please write or call the Payee

Payor Name(s)

Roulston's Account #

Address

Telephone

Signature of Payor(s)

check to confirm

Date

Branch #

Institution #

Account #

Name of financial institution

Branch

Branch address

City/Province

Postal Code

Preferred Store Location

Payee Name

Please specify whether the payment is:

Fixed amount

Variable amount

If fixed amount, please specify amount

if variable amount, please specify whether there is a maximum amount or indicate N/A if there is no max amount

Occuring at:

If you chose sporadic intervals, The Payor must describe the occurrence of an Event of other criteria that will trigger the debit of the account

Are top-ups or adjustments permissible?

Yes

Please include your email so we can confirm that we have received this form

Signature (First Account Holder)

check to confirm

Name (First Account Holder)

Signature (Second Account Holder)

check to confirm

Name (Second Account Holder)

Signature Date

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