NICE | Funeral Registration Form

Are you understand and agree to the policy.*
Please contact North Valley Islamic Center for any questions and clarification in regards to the policy, Thanks.
Applicant Contact
Applicant Last Name:*
Applicant First Name:*
Applicant Address:*
Applicant City:*
Applicant Province:*
Applicant Postal Code:*
Applicant Phone (Mobile):*
Applicant Email:*
Applicant`s DOB:*
Date Format: MM slash DD slash YYYY
Applicant Spouse:*
Spouse Last Name:*
Spouse First Name:*
Spouse DOB:*
Date Format: MM slash DD slash YYYY
Children & Siblings
Under 25 years/single/dependent/living at same address - FOR SIBLINGS ONLY
How many children you have:*
Child 1 Full Name:*
Child 1 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 2 Full Name:*
Child 2 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 3 Full Name:*
Child 3 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 4 Full Name:*
Child 4 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 5 Full Name:*
Child 5 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 6 Full Name:*
Child 6 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 7 Full Name:*
Child 7 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 8 Full Name:
Child 8 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 9 Full Name:*
Child 9 Date of Birth:*
Date Format: MM slash DD slash YYYY
Child 10 Full Name:*
Child 10 Date of Birth:*
Date Format: MM slash DD slash YYYY
Parents & In-laws
Are you registering your parents under a separate policy?*
Registering Both Parents (Father & Mother )?*
Select Parent:*
Applicant Father's Last Name:*
Applicant Father's First Name:*
Applicant Father's DOB:*
Date Format: MM slash DD slash YYYY
Applicant Mother's Last Name:*
Applicant Mother's First Name:*
Applicant Mother's DOB:*
Date Format: MM slash DD slash YYYY
Are you registering your In - laws as well under a separate policy?*
Registering Both In-laws? (Father & Mother )?*
Select In-law?:*
Applicant Father's In-laws Last Name:*
Applicant Father's In-laws First Name:*
Applicant Father's In-laws DOB:*
Date Format: MM slash DD slash YYYY
Applicant Mother's In-laws Last Name:*
Applicant Mother's In-laws First Name:*
Applicant Mother's In-laws DOB:*
Date Format: MM slash DD slash YYYY
Emergency Contact Info (Except Spouse)
Emergency Contact Last Name:*
Emergency Contact First Name:*
Emergency Contact Address:*
Emergency Contact City:*
Emergency Contact Province:*
Emergency Contact Postal Code:*
Emergency Contact Email:*
Emergency Contact Phone:*
Beneficiary Info
Beneficiary Last Name:*
Beneficiary First Name:*
Beneficiary Address:*
Beneficiary City:*
Beneficiary Province:*
Beneficiary Postal Code:*
Beneficiary Email:*
Beneficiary Phone:*
Witness
Witness Last Name:*
Witness First Name:*
Witness Address:*
Witness City:*
Witness Province:*
Witness Postal Code:*
Witness Email:*
Witness Phone:*
Witness's Signature:*
Witness Signature Date*
Date Format: MM slash DD slash YYYY
Applicant’s Signature:*
Applicant Signature Place:*
Applicant Signature Date:*
Date Format: MM slash DD slash YYYY
Pre-Authorized Debit (PAD) Agreement
North-Valley Islamic Centre (NICE)
(PAD) Date:*
Date Format: MM slash DD slash YYYY
(PAD) Would you like to support North-Valley Islamic Centre (NICE) to establish & spread "Islamic" in the city of Brampton through monthly contributions?*
(PAD) Please debit my account monthly for the following amount:*
(PAD) Other Amount $:*
(PAD) This donation is made on behalf of:*
Funeral Membership Details:
(PAD) You have registered above & paying ONE TIME REGISTRATION FEE of:*
Account Details
The debit will be processed to your account on the 20th day of each month or the next business day.
(PAD) Payment through:*
Please Fill up your bank information below:
(PAD) Bank Name:*
(PAD) Branch Address:*
(PAD) Bank Account Number:*
(PAD) Is this a joint account:*
Signature:*
Signature (Joint account holder):*
Please fill up your credit card details below:
(PAD) Name on the credit card*
(PAD) Credit Card Number*
(PAD) Expiration date*
(PAD) CCV number*
(PAD) Card Type #*
(PAD) Institution ID (3 Digits)*
(PAD) Branch ID (5 Digits)*
(PAD) Billing Address*
(PAD) City*
(PAD) Province*
(PAD) Postal Code*
(PAD) Account Holder’s Phone*
(PAD) Account Holder’s Email*
You, the Payer, may revoke your authorization at any time, subject to providing notice of 30 days. To obtain a Cancellation form, or for more information on your right to cancel a PAD Agreement, contact your financial institution or visit www.cdnpay.ca
The payer has certain recourse right if any debit does not comply with this agreement for example, payer have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on your recourse right, contact your financial institution or visit www.cdnpay.ca
If payer is only for North-Valley Islamic Centre (NICE)Funeral program Member, Payer Agree to pay registration fee and also reimbursed share of funeral cost, which will be divided equally to all members. If he/she fail (*3) to pay any funeral cost share, North-Valley Islamic Centre (NICE) has right to revoke your funeral membership. Members responsible to change any address, emergency name and number, beneficiary or additional applicate within family
Office Use Only
Member`s Number:
Received By (NICE):

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Applicant Contact

Children & Siblings

Parents & In-laws

Emergency Contact Info (Except Spouse)

Beneficiary Info

Witness

Pre-Authorized Debit (PAD) Agreement

Funeral Membership Details:

Account Details

Office Use Only

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