EXEMPTION FORM BANKING

Name of Club/Society/Indigenous Student Circle:*

Wishes to be exempt from normal banking procedures and to operate its own Bank Account.

Please describe your reasons for wanting a separate bank account:*

Please describe the safeguards which will be in place for this bank account:*

Name of signing officer #1

First Last

Address of signing officer #1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone number of signing officer #1

Email address of signing officer #1

Name of signing officer #1

First Last

Address of signing officer #2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone number of signing officer #2

Email address of signing officer #2

Name of financial institution*

Address of financial institution*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone number of financial institution*

Name of contact*

First Last

Telephone number of contact*

Email address of contact*

Name

This field is for validation purposes and should be left unchanged.