Funeral Service Registration Form

Please note: Under the Personal Information Protection and Electronic Document Act (PIPEDA), we require your consent when you provide us personal information. The purpose of collecting the information is to best serve you and used it in the future to contact you and to keep you informed. We respect your privacy rights.

I Agree
Yes No

Personal Details

First Name

Last Name

Address

City

Province

Postal Code

Primary Phone

Cell Phone

Citizenship Status

Interested in Volunteering
Yes No

Spouse Information

First Name

Last Name

Same As Primary Applicant

Address

City

Province

Postal Code

Phone no

Interested in Volunteering
Yes No

Add as a funeral service member
Yes No

Emergency Details

Full Name

Phone no

Relation

Acknowledgement

How many family members are included as members of CSFS (including yourself)

** Ontario Muslim Association (OMA) will charge each member of the Cost Sharing Funeral Service (CSFS) from your family, including yourself

By filling out this form, I consent to share personal details regarding myself and my family in accordance with the Personal Information Protection and Electronic Documents Act (PIPEDA) and understand that the information collected will be utilized for updates and activities related to CSFS by OMA.

As a component of this registration procedure, I give permission to the Ontario Muslim Association (OMA) for the Cost Sharing Funeral Services (CSFS) program to deduct CA$1/ person for myself and each family member chosen for pre-authorization.

I may revoke my authorization at any time, subject to providing notice of (Payee to insert period - not to exceed 30 days). To obtain a sample cancellation form or for more information on my right to cancel a PAD Agreement, I may contact my financial institution.

If I fail to pay my share of the funeral costs, OMA reserves the right to revoke my membership, and I may not be eligible for the services.

In the event of insufficient funds, the signing members shall be held responsible for all fees incurred by the bank.

I will be responsible for informing OMA, if there are any changes in my address, contact numbers, my bank information, or any change of my family member status.

E-Signature

Date

Pre-Authorized Payment Agreement of “Ontatrio Muslim Association (OMA)”

I grant permission to the Ontario Muslim Association (OMA) to automatically withdraw a maximum of CA$25 for each of family member from my bank account upon the death of a member. These occasional withdrawals will collectively fund the funeral service for a member. For instance, if there are 1000 members and the funeral service costs $7000, every member would need to contribute $7 via automatic withdrawal to cover the expense. If you have registered 5 members for the Cost Sharing Funeral Service (CSFS), including yourself, then OMA will debit $7 multiplied by 5 = $35 from your bank account. The maximum number of times we will perform automatic withdrawals in a year is 15. Should we need to withdraw more than 15 times, we will request approval from the members.

Banking Information

Transit Number

Institution Number

Account Number

Bank Name & Branch Name

I authorized Ontario Muslim Association (OMA) to withdraw the debit from my bank account on the day of or the next business day.

In the event of insufficient funds, the signing members shall be held responsible for all fees incurred by the bank.

Full Name

E-Signature (Full Name)

Submission Date

Ontario Muslim Association

Payment Calculator

Payment Amount: