DIRECT DEPOSIT INFORMATION

PLEASE PRINT CLEARLY (ALL SECTIONS MUST BE COMPLETED)

Full Name: Address:

Postal Code: City:

Treaty #: Phone Number:

I hereby authorize to credit payments through my account with the financial institution designated below, until canceled by me in writing.

Name of Bank: Branch Name:

Address: City:

Province: Postal Code:

Account Number: Select One:

Bank IdentificationNumber:

End Date:DAY MONTH YYYY

Signature:

Bank Transit Number:

“As long as the sun shines, the river flows and the grass grows...”

SavingsChequing

OR: New Direct Deposit/Pre-authorized Transactions Form(s) can be accessed from your banking institutions.

Note: We are on an electronic fund transfer system, therefore, no student allowance will be issueduntil we have been provided with the above information.

Post SecondaryEducation

LONG PLAIN FIRST NATIONTREATY ONE 287(35)POST SECONDARY DEPARTMENT

LONG PLAIN FIRST NATION110-5010 Crescent Road West, MB R1N 4B1

Phone: (204) 857-7474

Fax: (204) 857-7480Email: jdaniels@lpet.caWebsite: www.lpet.ca