Cancellation Form Annual Pass With Pre-Authorized Debit (Personal Pad)

FIDÉLITÉ PROGRAM

CANCELLATION FORM

Annual pass with pre-authorized debit (personal PAD)

Please ensure that all sections of the application have been completed.

1. ENROLMENT CANCELLATION (Complete sections 1, 2, 3 and 4)

Please indicate the last month you will use the pass:

Month (MM)

Year (YYYY)

Type of pass:

BASIC REGULAR

SENIOR

Reason for cancellation:

2. MEMBER INFORMATION

Last Name:

First Name:

Gender: F

Year of Birth:

My Smart Card No.:

(YYYY)

RESIDENTIAL ADDRESS

Number:

Street:

Apt. No.:

City:

Postal Code:

E-mail:

Home Telephone:

Work Telephone:

Extension:

3. MEMBER STATEMENT

To cancel enrolment in the "FIDÉLITÉ Program", complete the cancellation form and submit it to the STO’s

Finance Department by the 15

day of the month before the next scheduled debit date



I acknowledge that my “FIDÉLITÉ Program” smart card pass will become invalid on the first day of the month

following the notice of cancellation.



If my cancellation request is submitted before the one-year term has ended and for a reason other than those

accepted

, I shall owe the discount of 10% for each month of use of the annual pass (every month started shall be

due).



If my card was not adjusted at a service point when I requested the cancellation, within 30 days following termination

of my enrolment, I shall return the smart card linked to the contract to the STO

, failing which an additional amount of

$20.00 (tax exempt) will be debited from my account.

For more information on your right to cancel a PAD (pre-authorized debit) Agreement, contact your financial institution or

visit

Bank account debits are taken on the 25

day of every month or the next business day if the 25

falls on a weekend or holiday.

The annual enrolment can be cancelled at the member's request without any fees owing to the Société de transport de l'Outaouais when the member

is unable to use the pass for a period less three months for one of the following reasons:

 Stopped work (loss of employment or illness) – record of employment or medical certificate REQUIRED

 Death of the program member – declaration of death REQUIRED

 Maternity, parental or paternity leave – record of employment REQUIRED

Requests for refunds will not be accepted after the cancellation date, except for the reasons listed above.

In all cases, the STO's approval is required for the cancellation to become effective.

The “FIDÉLITÉ Program” smart card pass can be returned by mail to the STO’s administration office at 111 Jean-Proulx, Gatineau, J8Z 1T4, or

dropped off at one of the service points if the card was not adjusted when the cancellation request was processed.

I have read and agreed to the terms and conditions mentioned above.

4. MEMBER AUTHORIZATION

I hereby cancel my enrolment in the FIDÉLITÉ Program and the authorization to process pre-authorized debits on

my bank account. I acknowledge that this cancellation does not terminate any other obligation I may have towards

the beneficiary.

Member Signature

Account Holder Signature (if different)

Date (YY/MM/DD)

To have the cancellation request processed, please send this duly completed and signed form by mail to 111

Jean-Proulx, Finance Department, Gatineau, Quebec, J8Z 1T4, by fax to 819 770-5987, by e-mail to

fidelite@sto.ca

or dropped off at one of the STO Service Points (Galeries Aylmer, de la Cité or STO

administration office). Please print the form on legal size paper.

For more information, visit sto.ca, write to fidelite@sto.ca or call 819 770-3242.



_______________________________ ____________ ____________

If applicable, refund request if reason is valid.

Agent Signature

Date

Service Point

Cancellation Form Annual Pass With Pre-Authorized Debit (Personal Pad) - Sto

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