FIDÉLITÉ PROGRAM - MODIFICATION FORM

FIDÉLITÉ PROGRAM
MODIFICATION FORM
Annual pass with pre-authorized debit (personal PAD)

Please ensure that all sections of the application have been completed.

1. TYPE OF CHANGE

	ADDRESS		TYPE OF PASS		FINANCIAL INSTITUTION
	(Complete sections 2, 3 and 6)		(Complete sections 2, 4 and 6)		(Complete sections 2, 5 and 6)

2. MEMBER INFORMATION

Last Name : First Name: Gender :

Year of birth :	My Passe-Partout Plus card no. : CF-
		(6 digits under the photo)

RESIDENTIAL ADDRESS

Number : Street: Apt. No :
City : Postal Code : E-mail :
Home Telephone: ( ) -
Work Telephonel :( ) - Extension

3. ADDRESS CHANGE

Number: Street: Apt. No. :
City : Postal Code :
Home Telephone : ( ) -

Please indicate the date that the new address becomes effective :

4. CHANGE TYPE OF PASS

Please check the box for the desired change.

REGULAR to EXPRESS	EXPRESS to REGULAR	INTERZONE to REGULAR
REGULAR to INTERZONE	EXPRESS to INTERZONE	INTERZONE to EXPRESS
REGULAR to SENIOR (1)	EXPRESS to SENIOR (1)	INTERZONE to SENIOR (1)

(1) Proof of age is required.

I authorize the STO to change my type of pass.

Please indicate the desired start date of the pass :

Please indicate the Service Point where you wish to pick up the Passe-Partout Plus pass:

	GALERIES AYLMER		LES PROMENADES		STO (ADMINISTRATION)
	181, rue Principale Aylmer Sector		1100, boul. Maloney Ouest Gatineau Sector		111, rue Jean-Proulx Hull Sector

Please allow 15 days for the application to be processed. After the 25th of the month, you can go to the Service Point selected to exchange your annual Passe-Partout Plus pass for the new Passe-Partout Plus pass requested.

5. CHANGE IN FINANCIAL INSTITUTION

You must sent the STO a new sample check marked VOID, along with this duly completed form, before the 15th day of the month so that processing can be completed for the next debit date. You must make the necessary arrangements to ensure there is no interruption in monthly payments..

Please indicate the date that the new bank account becomes effective :

I authorize my financial institution to process a debit on my account for all amounts ordered by the Société de transport de l’Outaouais, for as long as my pass remains active.

6. MEMBER AUTHORIZATION


Member Signature	Account Holder Signature (if different)	Date (YY/MM/DD)

To have the modification request processed, please send this duly completed and signed form (with a cheque marked VOID if there is a change in financial institution) by mail to 111 Jean-Proulx, Finance Department, Gatineau, Quebec, J8Z 1T4, by fax to 819 770-5987, by e-mail to fidelite@sto.ca or dropped off at one of the STO Service Points (Galeries Aylmer, Les Promenades or STO administration office). Please print the form on legal size paper.

For more information, visit sto.ca, write to fidelite@sto.ca or call 819 770-3242.