Direct Deposit Request Form for Vendors

Protected "B" when completed.

General Instructions

This fillable form has been designed to make it easier for you to enrol in direct deposit. Please note that the completed form cannot be saved on your computer. Please print, sign and mail the completed enrolment form. There are two available formats, HTML and PDF (Document - 66 KB), both of which can be filled out on screen, printed and signed.

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 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.

Part A ‑ General Information

Purpose of the request (required)
Applicant's Information
Select a province or state
Provide the following if applicable:

Print: Part A ‑ General Information

Résumé des informations générales pour l'impression

  • Purpose of the request:

Applicant's Information

  • Legal Name of the Applicant:
  • Operating Business Name:
  • Address:
  • City:
  • Province/State:
  • Country:
  • Postal Code/ZIP Code:
  • Telephone:
  • Email Address:

Provide the following if applicable

  • Business or GST Number:
  • PST Number:
  • Social Insurance Number:

Part B ‑ Banking Information

  1. Cheque No. ‑ not required.
  2. Branch No. ‑ 5 digits.
  3. Institution No. ‑ 3 digits.
  4. Account No. ‑ as shown on your cheque.
Image d'un chèque en blanc avec la mention 'NUL' inscrit dessus
Account Type (required)

Confirmation of Financial Institution Official

Date (YYYY-MM-DD)

 

Financial Institutions Stamp Here (required when void cheque is not attached)

 

Résumé des informations bancaires pour l'impression

  • A void cheque with "VOID" written on it will be attached to the form: No
  • Branch No.:
  • Institution No.:
  • Account No.:
  • Swift Code for USA:
  • Account Type:
  • Name(s) of Account Holder(s) (if different from Legal Name of the Applicant):
  • Financial Institution Name, Address and Postal Code:
  • Telephone Number of Financial Institution:

Confirmation of Financial Institution Official

  • Date (AAAA-MM-JJ) :
  • Financial Institutions Stamp Here

Part C ‑ Consent

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.

Signature of Applicant

When printed, sign here.
Date
2017-12-15

Print: Part C ‑ Consent

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.

Résumé du consentement pour l'impression

  • Name of the Authorized Representative (Applicant):
  • Signature of Applicant:
  • Date: 2017-12-15

Part D - Send Form

Please ensure that you sign the form before mailing it.

To ensure that your information is not visible to other users of this computer, please click on "Clear data" after the form has been printed.

Where to Send Completed Forms

By mail:
Accounting Operations and Financial Policies – Vendor Records
Canadian Space Agency
6767 Route de l'Aéroport
Saint-Hubert, Quebec J3Y 8Y9

Date modified: