Form NWT9006 "Credit Card Authorization Form" - Northwest Territories, Canada

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Download Form NWT9006 "Credit Card Authorization Form" - Northwest Territories, Canada

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NWT Student Financial Assistance
CREDIT CARD AUTHORIZATION FORM
1. STUDENT INFORMATION
Last Name
First Name
Middle Name(s)
City/Community
Mailing Address
Territory/Province
Postal Code
Phone Number
Email Address (print clearly)
Date of Birth (YY/MM/DD)
2. PAYEE INFORMATION
, hereby authorize the Government of Northwest Territories –
I,
Student Financial Assistance to automatically debit my credit card in the amount of $
on the
of each month effective
or
this one time only.
These payments will be applied to my or
student loan.
3. CREDIT CARD INFORMATION
Name on Card
VISA
Mastercard
Card Type:
Number
Expiry Date (MM/YY)
4. AUTHORIZATION
(must be signed)
1.
In this Authorization ‘I’, ‘me’ and ‘my’ refer to each credit card holder who signs below.
2.
I allow the Government of Northwest Territories (the GNWT) to debit my credit card indicated above for the purpose of obtaining payment
for my NWT Student Loan.
3.
I may revoke this authorization at any time by submitting written notice within one month. I agree that revocation of this authorization does
not terminate any contract for the loan or money that exists between me and the GNWT.
4.
I will inform the GNWT, in writing, of any change to the credit card information provided in this authorization at least five (5) working days prior
to the next due date.
5.
I warrant that all persons whose signatures are required to sign on this credit card have signed this authorization.
This information is being collected under the authority of the Access to Information and Protection of Privacy Act (ATIPP), Section 40.(a) and (c)(i)
and the Student Financial Assistance Act and Regulations. The information will be used to determine my eligibility for the Northern Bonus and for
the general administration and enforcement of this program. The privacy provisions of ATIPP protect my information.
Personal information is defined under ATIPP, Section 2. All applicants have the right to examine and request correction of his or her records and to
request a review by the Information and Privacy Commissioner. If you have any questions about the collection of information, contact the Manager,
Divisional Financial Services, Income Security Programs Division, Department of Education, Culture and Employment, Box 1320, Yellowknife, NT,
X1A 2L9, or call 1-800-661-0793 or 1-867-767-9355.
X
Print Name
Signature of Credit Card Holder
Date - YY/MM/DD
PAGE 1 OF 1
NWT9006/0617
NWT Student Financial Assistance
CREDIT CARD AUTHORIZATION FORM
1. STUDENT INFORMATION
Last Name
First Name
Middle Name(s)
City/Community
Mailing Address
Territory/Province
Postal Code
Phone Number
Email Address (print clearly)
Date of Birth (YY/MM/DD)
2. PAYEE INFORMATION
, hereby authorize the Government of Northwest Territories –
I,
Student Financial Assistance to automatically debit my credit card in the amount of $
on the
of each month effective
or
this one time only.
These payments will be applied to my or
student loan.
3. CREDIT CARD INFORMATION
Name on Card
VISA
Mastercard
Card Type:
Number
Expiry Date (MM/YY)
4. AUTHORIZATION
(must be signed)
1.
In this Authorization ‘I’, ‘me’ and ‘my’ refer to each credit card holder who signs below.
2.
I allow the Government of Northwest Territories (the GNWT) to debit my credit card indicated above for the purpose of obtaining payment
for my NWT Student Loan.
3.
I may revoke this authorization at any time by submitting written notice within one month. I agree that revocation of this authorization does
not terminate any contract for the loan or money that exists between me and the GNWT.
4.
I will inform the GNWT, in writing, of any change to the credit card information provided in this authorization at least five (5) working days prior
to the next due date.
5.
I warrant that all persons whose signatures are required to sign on this credit card have signed this authorization.
This information is being collected under the authority of the Access to Information and Protection of Privacy Act (ATIPP), Section 40.(a) and (c)(i)
and the Student Financial Assistance Act and Regulations. The information will be used to determine my eligibility for the Northern Bonus and for
the general administration and enforcement of this program. The privacy provisions of ATIPP protect my information.
Personal information is defined under ATIPP, Section 2. All applicants have the right to examine and request correction of his or her records and to
request a review by the Information and Privacy Commissioner. If you have any questions about the collection of information, contact the Manager,
Divisional Financial Services, Income Security Programs Division, Department of Education, Culture and Employment, Box 1320, Yellowknife, NT,
X1A 2L9, or call 1-800-661-0793 or 1-867-767-9355.
X
Print Name
Signature of Credit Card Holder
Date - YY/MM/DD
PAGE 1 OF 1
NWT9006/0617