payment authorization form for balance transfer

PAYMENT AUTHORIZATION FORM
FOR BALANCE TRANSFER
CONFIDENTIALITY: This document is intended solely for the individual or entity to whom it is addressed. The information contained in this document is legally
privileged and confidential. If you are not the intended recipient or the person responsible for delivering it to the intended recipient, you are hereby advised that
you are strictly prohibited from reading, using, copying or disseminating the contents of this document. Please inform the sender immediately or write to
[email protected] and delete this document immediately.
CONFIDENTIALITÉ : Ce document est destiné uniquement à la personne ou à l'entité à qui il est adressé. L'information apparaissant dans ce document est de
nature légalement privilégiée et confidentielle. Si vous n'êtes pas le destinataire visé ou la personne chargée de le remettre à son destinataire, vous êtes, par la
présente, avisé que toute lecture, usage, copie ou communication du contenu de ce document est strictement interdit. De plus, vous êtes prié de communiquer avec
l’expéditeur sans délai ou d’écrire à [email protected] et de détruire ce document immédiatement.
1
HOLDER OF A NATIONAL BANK MASTERCARD CREDIT CARD
I hereby authorize National Bank to transfer the balance of my credit card account(s) from another company or financial institution to the
1
National Bank MasterCard account listed below. I understand that my balance(s) will only be transferred if the National Bank MasterCard
account is in good standing. Each amount listed below cannot be less than $250.00. I understand that a fee of 3% of the amoun t transferred
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will be charged to the Bank’s MasterCard account.
First and last name of client
Home telephone No.
NATIONAL BANK
MasterCard
Office telephone No.
5258
Account No.
Name of issuing institution
Amount of balance(s)
outstanding to be
transferred
Account No.
$
Visa
$
MasterCard (other financial institution)
$
Other
$
Other
Date (YYYY MM DD)
Signature of client
Date (YYYY MM DD)
Signature of employee
1.
2.
2
Employee no.
Transit
I certify that the credit card account whose balance I would like to transfer is in good standing and I authorize National Bank to verify
the status and balance of that account.
Balance transfers are treated as cash advances and are subject to the Agreement governing the use of the MasterCard credit card
issued by the Bank. In particular, the interest on the cash advance amounts begins to accrue as of the cash advance date, until full
payment is received. The Bank reserves the right to refuse any balance transfer.
This fee may be reduced if a promotional offer is available.
NON-HOLDER OF A NATIONAL BANK MASTERCARD
Complete an application form including section for Transfer of balance
Please return this document by fax to 514-394-8772 / 1-866-394-8772 or via Internal Mail to transit 1569-1.
National Bank is a trademark used by National Bank of Canada.
13145-002 (2014-10-03)