Pre Authorized Debit Form


Please Fill out the information below or upload a picture of a void cheque. 

Upload File
Max File Size 15MB

Consent and Disclosure Regarding Personal Consent


I/We consent to the disclosure of any personal information that may be contained on this Payor’s PAD Agreement to the Alberta Treasury Branch, as far as any such disclosure of personal information is directly related to and necessary for the proper application of this PAD Agreement. I/We acknowledge that providing and delivering this authorization to Midpark Christian Assembly AKA Knexions Church constitutes delivery by me/us to the ATB. Any delivery of this authorization to ATB constitutes delivery.

Midpark Christian Assembly AKA Knexions Church is requested and authorized to make withdrawals from the above account, for the purpose of “Charitable Donations”, under the following terms:

1.  Withdrawals will be made according to the payment frequency indicated above.

2.  You, the Payor, may revoke your authorization at any time, subject to providing written notice of 10 days to Midpark Christian Assembly AKA Knexions Church.

3. A PAD may be distributed by a payor under the following conditions:

(i)The PAD was not drawn in accordance with the Payor’s PAD Agreement; or

(ii)The Payor’s PAD Agreement was revoked; or

(iii)Pre-notification was not received and pre-notification was required under the terms of the Payor’s PAD Agreement.

The payor, in order to be reimbursed, acknowledges that a declaration to the effect that either (i), (ii), or (iii) took place, must be completed and presented to the branch of the processing member holding the payers account up to and including 90 days after the date on which the PAD in dispute was posted to the payor’s account. Tee payor acknowledges that a claim on the basis that the Payor’s PAD agreement was revoked, or any other reason, is a matter to be resolved solely between the payee and the payor when the disputing any PAD after 90 calendar days.

4.  I/We acknowledge that the above designated funds will be deposited in accordance with Midpark Christian Assembly AKA Knexions Church’s Stewardship Policy which states: All gifts are tax deductible. Gifts designated for a specific project or ministry will be used as specified with the understanding that if the project or ministry is fully funded or cannot be carried out for any reason, our Board will seek God’s direction and apply these funds to another pressing need. Spending of funds is confined to Board approved projects and ministries. Midpark Christian Assembly AKA Knexions Church’s financial statements are reviewed annually by an independent public accounting firm and are available upon request.

By clicking Submit, you agree to the Consent and Disclosure Personal Consent Agreement.

  • White Facebook Icon
  • White Instagram Icon
  • White Twitter Icon
  • email icon white

phone: 403-256-4722
mailing address: PO Box 44122 Southcentre RPO
Calgary, AB  T2J 7C5

​Knexions church is an operating trade name of Midpark Christian Assembly. Proudly created with