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Downtown Simcoe (Map)

Phone 519-426-1731 | Email

  • Monday: 9am to 6pm
  • Tuesday: 9am to 6pm
  • Wednesday: 9am to 6pm
  • Thursday: 9am to 8pm
  • Friday: 9am to 8pm
  • Saturday: 9am to 4pm
  • Sunday: 11am to 3pm

Wellness Centre (Map)

Phone 519-426-8011 | Email

  • Monday: 9am to 6pm
  • Tuesday: 9am to 6pm
  • Wednesday: 9am to 6pm
  • Thursday: 9am to 6pm
  • Friday: 9am to 6pm
  • Saturday: 9am to 4pm
  • Sunday: 11am to 3pm

Port Dover (Map)

Phone 519-583-2100 | Email

  • Monday: 9am to 6pm
  • Tuesday: 9am to 6pm
  • Wednesday: 9am to 6pm
  • Thursday: 9am to 6pm
  • Friday: 9am to 6pm
  • Saturday: 9am to 4pm
  • Sunday: 11am to 3pm

Delhi (Map)

Phone 519-582-1800 | Email

  • Monday: 9am to 6pm
  • Tuesday: 9am to 6pm
  • Wednesday: 9am to 6pm
  • Thursday: 9am to 6pm
  • Friday: 9am to 6pm
  • Saturday: 9am to 4pm
  • Sunday: 11am to 3pm

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

Payor Information

Payor Name(s)
 
Address
 
Telephone
 
Signature of Payor(s)
 
Date
 

Payor Financial Institution/Banking Information

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Branch #
 
Institution #
 
Account #
 
Name of financial institution
 
Branch
 
Branch address
 
City/Province
 
Postal Code
 
Preferred Store Location
 

Payee Information

Payee Name(s):

Roulston's Discounts Drugs, Limited

Address:

17 Norfolk Street, South, Simcoe, ON N3Y 2V8

Telephone:

519-426-1731 ext. 243

Fax:

519-426-6194

Email:

bridgetb@roulstons.com

Payee Name
 

Payment Information

Please specify whether the payment is:
 
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?
 
Please include your email so we can confirm that we have received this form
 

Terms and conditions

PAYOR'S PAD AGREEMENT
Personal Pre-Authorized Debit Plan
Terms & Conditions
December 2008

1. in this Agreement, "I", "me" and "my" refers to each Account Holder who signs below.

2. I agree to participate in this Pre-Authorized Debit Plan for personal/household or consumer purposes.
I authorize the Payee indicated on the reverse hereof and any successor or assign of the Payee to draw a debit in paper, electronic or other form for the purpose of making payment for consumer goods or service (a "Personal PAD") on my account indicated on the reverse hereof (the "Account") at the financial institution indicated on the reverse hereof (the "Financial Institution").
I authorize the Financial institution to honour and pay such debits.
This Agreement and my authorization are provided for the benefit of the Payee and my Financial Institution and are provided in consideration of my Financial Institution agreeing to process debits against my Account in accordance with the Rules of the Canadian Payments Association.
I agree that any direction I may provide to draw a Personal PAD, and any Personal PAD drawn in accordance with this Agreement, shall be binding on me as if signed by me, and, in the case of paper debits, as if they were cheques signed by me.

3. I may revoke or cancel this Agreement at any time upon notice being provided by me either in writing or orally. I acknowledge that in order to revoke or cancel the authorization provided in this Agreement, I must provide notice of revocation or cancellation to the Payee.
This Agreement applies only to the method of payment and I agree that revocation or cancellation of this Agreement does not terminate or otherwise have any bearing on any contract that exists between me and the Payee.
The Payee shall use best efforts to cancel the PAD in the next business, billing or processing cycle but shall within not more than 30 days from the notice cease to issue any new PADs.
I understand that I may obtain a sample cancellation form, or further information on my right to cancel a PAD Agreement, at my financial institution or at ww.cdnpay.ca.

4. I agree that my Financial Institution is not required to verify that any Personal PAD has been drawn in accordance with this Agreement, including the amount, frequency and fulfillment of any purpose of any Personal PAD.

5. I agree that delivery of this Agreement of the Payee constitutes delivery by me to my Financial Institution. I agree that the Payee may deliver this Agreement of the Payee's financial institution and agree to the disclosure of any personal information which may be contained in this Agreement to such financial institution.

6 (a) I understand that with respect to:
(i) fixed amount Personal PADs occurring at set intervals, I shall received written notice from the Payee of the amount to be debited and the due date(s) of debited, at least ten (10) calendar days for Payer Agreements, fifteen (15) Electronic Agreements before the due date of the first Personal PAD, and such notice shall be received every time there is a change in the amount or payment dates(s);
(ii) variable amount Personal PADs occurring at set intervals, I shall received written notice from the Payee of the amount to be debited and the due dates(s) of debited, at least ten (10) calendar days before the due date of every Paper PAD/ 15 calendar days for Electronic PADs before the due date of the first personal PAD; and
(iii) fixed amount and variable amount of every Paper and/or Electronic Personal PADs occurring at set intervals, where the Personal PAD Plan provides for a change in the amount of such fixed and variable amount PADs as a result of my direct action (such as, but not limited to, a telephone instruction) requesting the Payee to change the amount of a PAD, no pre-notification of such changes is required.
- OR -
(b) I agree to either waive the pre-notification requirements in section 69a) of this Agreement or to abide by any modification to the pre-notification requirements as agreed to with the Payee.

7. I agree that with respect to Personal PADs, where the payment frequency is sporadic, a password or secret code or other signature equivalent will be issued and shall constitute valid authorization for the Payee or its agent to debit my account.

8. I certify that all information provided with respect to the Account is accurate and I agree to inform the Payee, in writing, of any change in the Account information provided in this Agreement at least ten (10) business days prior to the next due date of a Personal PAD. In the event of any such change, this Agreement shall continue in respect of any new account to be used for Personal PADs.

9. I understand that I have certain recourse/reimbursement 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 PAD Agreement. I understand that I may obtain more information on my recourse/reimbursement rights by contracting my financial institution or visit the CPA website at www.cdnpay.ca.

10. I warrant and guarantee that all persons whose signatures are required to sign on the Account have signed this Agreement below. In addition I warrant and guarantee, where applicable, that I have the authority to electronically agree to commit to this Agreement by secure electronic signature and that my secure electronic signature conforms to the requirements of Rule H1.

11. I agree that a payment service provider will administer the PAD. [INSERT NAME] will be administering the PAD.

12. I understand and agree to the foregoing terms and conditions.

13. I agree to comply with the Rules of the Canadian Payments Association or any other rules or regulations with may affect the services described herein, as may be introduced in the future or are currently in effect and I agree to execute any further documentation which may be prescribed from time to time by the Canadian Payments Association in respect of the services described herein.

14. Applicable to the Province of Quebec only: Is is the express wish of the parties that this Agreement and any related documents be drawn up and executed in English. Les parties conviennet que la presente convention et tous les documents s'y rattachant soient rediges et signes en anglais.

Signature (First Account Holder)
 
Name (First Account Holder)
 
Signature (Second Account Holder)
 
Name (Second Account Holder)
 
Signature Date