Pre-Authorized Payment Information Form


Please complete the online form below for pre-authorized payment from a credit card or bank chequing or savings account.
   
McMaster Student ID:
Student Long Distance Authorization Code:
Home Phone Number:
Email Address:
   
By providing this information, you are authorizing the financial institution or credit card company indicated, to release funds to SelectCom Inc. for payment of monthly-billed charges. You may cancel or amend this payment authorization at any time by calling Customer Service at 1-800-497-5570. Pre-authorized payment will be withdrawn on the first business day of each month following the issue of invoice.

Please enter your initials in the following box to confirm you have read and understand the above:
   
Banking Information
Name of Account Holder:
Name of Bank:
Transit Code (5 digits):
Bank Code (3 digits):
Account Number (min 7 digits):
   
Credit Card Information
Card Type:  MasterCard  Visa
Card Holder Name:
Card Number:
Expiry date (mmyy):
 
Please fax a copy of your void cheque to 1-800-272-1031
or
Mail to:
SelectCom Inc.
400-987 Wellington Street
Ottawa, ON K1Y 2Y1