Pre-Authorized Loan Payment Agreement

To set up your loan payments, fill out the authorization form below and submit.

Payment is by pre-authorized automatic monthly payments from a Canadian bank. The minimum monthly payment is $100 for loans of $6,000 or less, or $200 for loans over $6,000.  If you wish, you may pay a higher amount, or pay the loan in full.

You must inform the MAA office of any changes to your address and contact information, as per the loan agreement you signed. If you move, remember to update your contact information.

Contact Information

First Name *

Last Name *

Email *

Alternate Email

Student Number *

Year of Graduation *

Current Address

Address *

Apt/Suite/Unit *

Please enter your unit number or enter N/A

City *

Province *

Postal Code *

Current Address is the same as your Permanent Address *YesNo

Permanent Address

Address

Apt/Suite/Unit

City

Province/State

Postal Code/Zip Code

Country

Phone *

Additional comments regarding Contact Information

Bank Information

Name of Banking Institution *

Bank's Full Address or Intersection *

Branch Transit # *

Institution # *

Account # *

Indicate Monthly Payment Amount *100200Other

If you wish to pay more per month, or pay the loan in full, indicate the amount. *

Update Contact Information *

I agree to keep the Medical Alumni Association regularly informed of my current address, phone number and email until the loan is paid in full.

Authorization *

I authorize the MAA to debit the amount indicated above every month from my bank account on the first of the month starting July 1, 2021.

Digital Signature *

Typing your name above acts as a digital signature

Date *

Today's date

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