Automatic Bank Withdrawal
Date
YYYY-MM-DD
Sponsor Number
Name*
Address
City
Province
or State
Postal Code
Telephone
Evening Phone
Email
Bank Routing Number
Bank Account Number
To be withdrawn from
Chequing Account
Savings Account
Amount
Withdrawal date
15th
Every
Monthly
Annual
© International Child Care Ministries in Canada
International Child Care Ministries in Canada
4315 Village Centre Court
Mississauga ON L4Z 1S2
Phone: (905) 848-2600