You are on page 1of 2

Pre-Authorized Debit Agreement (PAD Agreement)

In order to set up a bank account for scheduling online payments, you must submit a completed and
signed PAD Agreement and a void cheque. This form authorizes Imperial Oil to debit your account when
you schedule an online payment from a specific bank.

PAD Agreement Instructions


ƒ Complete the PAD Agreement form on page 2 of this document.
ƒ Please refer to one of your cheques to find the Branch Transit Number, Financial Institution
Number and Account Number. The Branch Transit Number and Financial Institution Number
comprise the routing number required for us to debit your account.

ƒ You can fax or mail the completed and signed agreement.


ƒ Be sure to include a void cheque with the agreement.
ƒ If the form is not complete or if the information is found to be incorrect, you may be requested to
submit a new form or contact us when online corrections are made to your routing or account
number.

Bank Account Setup Process


ƒ When you first enter a new bank account, the status will be indicated as PENDING. While the
status is Pending, you will not be able to schedule payments from your bank account.
ƒ Once we receive and approve your completed PAD Agreement, along with a void cheque, the
status will change to APPROVED.
ƒ You will receive an e-mail notification that your setup is complete. You will then be able to
schedule payments from your bank.

Privacy Policy
For information on Imperial Oil Limited's privacy policy on the collection, use and disclosure of your
information, please review the Privacy Statement on our website at www.imperialoil.ca. Please note that
the information collected for this Agreement may be stored by a third party storage provider in the United
States and therefore may be subject to the disclosure laws of that country. Imperial Oil Limited assures
you that it will maintain a sufficient data privacy agreement with any storage provider under contract in
order to safeguard your information. In the event that we are notified of a requirement by law to disclose
your personal information, we will use best efforts to notify you in advance and without delay in order to
provide you with an opportunity to oppose or respond to the requirement accordingly.

If you have any questions, please call Customer Service at 1-800-267-0156.

IOL.PAD.INST (4/09)
INDIVIDUALLY APPROVED PRE-AUTHORIZED DEBIT AGREEMENT ("PAD AGREEMENT")
Fleet and Small Business

1. Customer Information (please print clearly)


Customer Name: Customer Number:
Mailing Address:
City: Province: Postal Code:
Telephone Number: Fax Number:
Email Address:
Type of Service: Business _____ Personal _____

2. Bank Account Information


Bank Account Number: Branch Transit Number:
Financial Institution Number: Financial Institution Name:
Branch Address:

3. Pre-Authorized Debit Details


The undersigned ("Payor") hereby provides authorization to Imperial Oil Limited, its affiliates and partnerships ("Imperial Oil) and the financial
institution designated to process debits by electronic entry from time to time, for payments of any or all charges arising under the Payor’s Imperial
Oil Fleet and/or Small Business account(s) as authorized by the Payor. Imperial Oil shall obtain due authorization from the Payor in accordance with
Rule H1 of the Canadian Payment Association for each and every PAD that it issues. Imperial Oil intends to use Wright Express Corporation to
administer the PAD. Imperial Oil may not assign this authorization, whether directly or indirectly, by operation of law, change of control, or
otherwise, without providing at least 10 days prior written notice to the Payor.

The Payor hereby waives any and all PAD pre-notification requirements otherwise required by Rule H1.

The PAD Agreement is to remain in effect until Imperial Oil has received written notification from the Payor of its change or termination. Imperial
Oil must amend or terminate the PAD Agreement within 30 days from the time it receives notice from the Payor. To obtain a sample cancellation
form, or for more information on the Payor's right to cancel a PAD Agreement, contact your financial institution or visit www.cdnpay.ca. The
revocation of the PAD Agreement by the Payor does not terminate any contract for goods or services that exists between the Payor and Imperial Oil.

The Payor has certain recourse rights if any debit does not comply with this agreement. For example, the Payor has the right to receive
reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on the Payor's recourse
rights, contact your financial institution or visit www.cdnpay.ca.

The Payor acknowledges that the information contained in the Authorization may be disclosed to Imperial Oil's financial institution(s), as may be
required or desirable to complete any PAD transaction. (Applicable to the Province of Quebec only: Such consent constituting the consent required
under the Act pertaining to the protection of personal information in the private sector (L.R.Q.c.P.39.1)).

Name of “Payor” (Business name, Individual name, etc.)

Authorized Signatory Authorized Signatory (if appropriate)

Name (please print) Name (please print)

Date Date

4. Contact Information
Please mail or fax the completed form and void cheque to: Wright Express Corporation
Treasury Group
97 Darling Avenue
S Portland, ME 04106
USA
Fax: (207) 523-7699

Inquiries may be made by phoning: Tel: (207) 523-6022