Pre-Authorized Chequing Form:

I hereby authorize Youth for Christ/Canada to draw and issue cheques on the 1st or 16th day of each month for payment of my pledge for Highlands Youth for Christ.

                               _______1st                16th________

In the amount of $______________________________________

Name: _______________________________________________

Bank: ________________________________________________

Branch: ______________________________________________

Bank Address: _________________________________________

City: _______________________Province: __________________

Type of Account: _______________________________________

Account Number: _______________________________________

Signature(s) as required on cheques against account:

_____________________________________________________

_____________________________________________________

Please include a sample cheque marked VOID.  This authorization may be cancelled at any time upon notice (please allow 3-4 weeks for processing)