Quadrant Newmedia Pre-authorized Payment

Quadrant Newmedia Pre-authorized Payment Signup Form

Please fill out the following form, and then submit the application and accept the terms and conditions by clicking on the button below. A copy of your application will be emailed to your account, and another copy will be sent to "billing@quadrant.net".
Note: your bank account will be debited on or about the 15th of the month, for the full amount of your invoice for that month (which you will receive near the 1st of the month). If you have any questions about your bill, you must contact us before the 10th of the month; otherwise, any changes to your bill will appear on your next invoice.

If you have any questions, please contact billing@quadrant.net


Personal Information
Account or Domain Name:
First name:
Last name:
Phone:
Address:
City:
Postal Code:

Financial Institution Information
Bank Name:
Branch Name:
Address:
City:
Postal Code:

Account Information (the numbers from the bottom of your cheques)
	Note: this information can be found at the bottom of any of your cheques (in a "computer-readable" font). All cheques will have at a minimum the "5 - 3 - (acct #)" pattern. Some cheques additionally have the cheque number encoded before the transit number, or may have additional numbers after the account number. These may be ignored.
Transit Number:	(5 digits)
Financial Institution #:	(3 digits)
Account Number:	(remaining digits (5-16))
Account Type:	Chequing Savings

I hereby authorize Quadrant Newmedia Corp. to debit my account for outstanding charges for Internet services provided to me.