Salary Deduction Order | Fond St Jacques Credit Co-Operative Society Ltd.:

SALARY ASSIGNMENT/DEDUCTION ORDER/STANDING ORDER

Date

This order replaces previousThis order is an addition to previous

I, the undersigned customer hereby authorize you to pay

dollars

cents

$

the full amount of my salary/gratuity to the Fond St Jacques Credit Co-operative Society Limited for the credit of my

account #

commencing

and ending

This instruction can only be altered or cancelled according to the condition(s) selected below

Can be revoked only by the written authorization of the Fond St Jacques Credit Co-operative Society Limited

Can be revoked by the undersigned customer or written authorization of the Fond St Jacques Credit Co-operative Society Limited (whichever is earlier).

Can be revoked by the written authorization of the undersigned customer

In consideration of your compliance I hereby release and discharge the aforementioned company from any liability it might incur in satisfying these instructions. Kindly imprint your stamp and signature as confirmation of receipt and acceptance of these instructions and return a copy to the Fond St Jacques Credit Co-operative Society Limited

Yours Faithfully

______________________________

Employee's Signature

______________________________

Authorized Signature (Company)

Authorized Signature (Institution/Third Party)

For use by Fond St Jacques Credit Co-operative Society only:

Amount of Deduction $

______________________________
Employee's Signature

Allocation:

Shares $

Deposots $