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Employee Name: Employee#: 807213David Todica
EMPLOYEE ELECTION FormI wish to continue with my:
Check one:
~ Basic benefit coverage and pension ($484.01) or;
o Basic benefit ($239.95) or;
o Pension coverage ($244.06) or;
o I decline to continue both my benefit and pension coverage
I, l> Pt'l\j) 10D\ CA ,#~D1d\3,acknowledge I am responsiblefor payment of any benefit or pension coverage I have elected to continue duringmy absence.
I understand I will be not be covered for any optional benefit I declined (includingMSP or AHC, if applicable) and must re-apply for coverage upon my return to activeemployment.
I also understand Jazz will not match my contributions if I decline to contributetowards the pension plan.
Signed:_~-=====~,~A=::::.<::-=~=-====- _ C'~\Dated: 2:>'-''\ \Month Day Year
Return one copy of this form and, if applicable, Direct Withdrawal form to theBenefits Department within 31 days
Air Canada JazzAttention: Gloria Metcalfe
310 Goudey DriveEnfield, NS B2T 1E4
Fax to Gloria 902-468-2272
Fax, Mail or E-mail to Gloria Metcalfe,[email protected] 902-468-2272 (fax)
Direct Withdrawal Authorization & A reementDavid Todica909 Russet Rd N.E.Calgary, AB,T2E5K8
EE # 807213Employee's email: d..±.ocl~(:Q.fa)~\n.CL.W.e
September 01,2010Home Telephone No.
Savings Account DDeposit Account No.: Branch Transit No.:
Chequing AccountFinancial Institution No.:
Name:Financial Institution:
-\\1':\\ \;;2. p..,\lc CJ::>Lf.ACO-j,
--;}.~ btV&Branch Address: \d-.\" c.e~~ S, _N
*For verification, please attached a VOID cheque.
I acknowledge that this Authorization is provided for the benefit of the Company and the Bank, and is provided inconsideration of the Bank agreeing to process debits against my account in accordance with the rules of theCanadian Payments Association (CPA).
1. Purpose of Debits: Personal Pre-Authorized Debit (PAD)
2. Pre Notification of AmountsFixed Amounts: Jazz Air LP will provide written notice to the. employee of the amount to be debited and the date
of the debit at least ten (10) calendar days before the date of the first debit and every time there is a change in theamount or payment date.
Signature of Employee: .!-- Signature of Company: _
3. Terms of Authorization to debit the Above AccountThe employee authorizes the Company to debit or cause to be debited the following amount from the aboveaccount. It is a fixed amount of $ 4g,4.0\ which will be debited within the third week of every monthcommencing September 01, 2010 for your leave.
The employee acknowledges that in order to revoke or cancel this Authorization the employee must providenotice of revocation or cancellation to the Company, in writing, email, or fax within thirty 30 days before the dateof the next debit. To obtain a sample cancellation form, please contact your Benefit Coordinator. For moreinformation on your right to cancel a PAD Agreement, please visit www.cdnpay.ca. Cancellation or revocation ofthis Authorization does not terminate any contract for goods or services that exists between the employee and theCompany. This Authorization applies only to the method of payment.
The employee has certain recourse rights if any debit does not comply with this agreement. For example, theemployee has the right to receive reimbursement for any debit that is not authorized or is not consistent with thisPAD Agreement. To obtain more information on my recourse rights visit www.cdnpay.ca.
The employee warrants that all information provided with respect to the above account is complete and accurate.The employee undertakes to inform the Company, in writing, of any change in the account information provided inthis Authorization prior to the date of the next debit. The Employee acknowledges that any delivery of thisAuthorization to the Company constitutes delivery by the employee to the Company and the Bank. The employeewarrants and guarantees to the Company and the Bank that all persons whose signatures are required to sign onthe above account have signed this Authorization. The employee acknowledges receipt of a signed copy of thisAuthorization. The employee acknowledges that they have read, understand, and accepts the terms andconditions of this Authorization.
DAVID OR IOANA TODICA
MEMO~ ~ __ ~ __ ~~ __ ~ __ ~~,
