CANCELLATION FORM - FIDÉLTÉ

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This form is for people enrolled in the FIDÉLITÉ Program who would like to cancel their annual enrolment with pre-authorized debit (PAD).

The deadline for submitting this form is the 15th of the month before the month in which the cancellation/suspension is to take effect.

Once the form has been submitted, there is no need to submit it again to cancel/suspend for future months.

Please be sure to fill out every section of the form.

SECTION 1 : MEMBER INFORMATION

Please fill in the following information :

Last Name *

First Name *

Gender

Other

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Year of Birth (YYYY)

Residential Address

Civic number, flat or apartment and street name *

City *

Postal Code *

Contact Information

Please fill in the following information :

E-mail (You will receive an e-mail confirmation in a few days)

Home Telepone (819-555-3333) *

Work Telephone and Extension

SECTION 2 : ENROLMENT CANCELLATION

Please fill in the following information :

Type of pass *

Reason of cancellation

Smart Card No. (16 numbers) *

Please indicate the month in which you would like your cancellation/suspension to take effect (the request for cancellation/suspension must be submitted no later than the 15th of the previous month)

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