Assalam Mosque - Mosque Pledge Form


I am sending my monthly pledges,
$1000
$500
$250
$100
$50
Other

Personal Information

Name
Address
City, Province
Postal Code
Tel
Email

Bank Information

Starting with the 1st day of
I am giving my permission to The Ottawa Islamic Center and Assalam Mosque Project to withdraw from my Bank Account the pledge I have indicated above. I will also notify the payee in writing of any changes in the account information of this authorization prior to the due date of the pre-authorized debit.
Bank Name
Account Number
Branch Transit Number

TD Canada Trust 2470 Bank Street Ottawa ON K1V 8S2 Branch # 5336 Transit # 8387 Account # 5207190
Payable to: The Ottawa Islamic Centre and Assalam Mosque 100-2335 St. Laurent Blvd Ottawa ON K1G 5G6 Tel. (613) 739-3939 Fax. (613) 739-1132