HTML Preview Vendor Direct Deposit Form page number 1.
PRIVACY NOTICE Personal information is collected under the Financial Administration Act,
Subsections 17(1) and 35(2). The Canadian Space Agency shall disclose information to
relevant federal institutions and your financial institution. Direct deposit payments cannot be
made without provision of requested information.
Personal information is protected, used and disclosed in accordance with the Privacy Act, and
as described in Personal Information Bank CSA PPU 045 – Grants and Contributions –
Research Component. Under the Act, you have the right to access and correct your personal
information, if erroneous or incomplete.
Third party information provided by companies shall be protected, used and disclosed in
accordance with the Access to Information Act.
Direct Deposit Request Form For Vendors
Part A: To be completed by applicant
Preferred language English French
1
Purpose of the request
Start Direct Deposit Change Direct Deposit Information Stop Direct Deposit
2
Legal Name of the Applicant
(Business or Individual
Applicant Name)
3
Operating Business Name
4
Address
City Province / State
Postal Code Country Telephone
Email Address
5
Provide the following if applicable:
Business or GST Number
QST Number
Social Insurance Number (Individuals only)
P
art B:
Complete Part B and have it confirmed by your financial institution OR for Canada only, attach a voided cheque and complete Box 7.
6
Branch No.
Swift Code for USA:
Inst. No.
Account Number
7
Name(s) of Account Holder(s) – if different from Box 2:
8
Financial Institution Name, Address and Postal Code
Telephone Number of
Financial Institution
9
Confirmation of Financial Institution Official
Financial Institution’s Stamp Here
Date
Part C:
I, the undersigned, have read the Privacy and Third Party Notice, and I consent to the collection, use and disclosure of my information as described therein.
I, as an authorized representative of this business, grant the Receiver General for Canada the right to deposit future payment(s) from the Canadian Space
Agency directly into the bank account specified until further notice.
10
Name of the Authorized Representative (Applicant)
Block letters
11
Signature of Applicant
X
Date