ATB Direct Deposit/Debit Form

Customer/Account Information
Name:
First
Middle
Last
Address:
Unit/ Apt #
Street
City
Province
Postal Code
Telephone Numbers:	( ) -
( ) -
( ) -
Home
Mobile
Alternate
Transit	Institution	Account #
ATB Financial:	219
For the purpose of:	Direct Deposit	Direct Debit
Company Name:
I, the undersigned:
Certify that the information on this form is true and correct
Consent to the exchange of this information for the purpose of an electronic funds transfer between ATB Financial and the company/creditor named above
Understand that the use, disclosure and storage of this form remains the responsibility of myself and/or the direct creditor/debitor.
Customer Signature
Stamp Here (if applicable)

™ Trademarks of Alberta Treasury Branches.

Page 1 of 1

Form 20914 (07/14)

#####

E25935

2014-06-10

ATB Financial