PetraHOW Membership Enrollment

HOWffer Membership Fee

Coverage Level

Member OnlyMember + SpouseMember + Child(ren)Family

$

Billing address same as mailing address?*

YesNo

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Payment Method:

Credit CardACH / Bank Draft

This is an authorization to allow the Third Party Administrator to regularly charge my card the membership fee indicated on this form on a monthly basis. This agreement and the coverage shall remain in effect until I request cancellation or termination.

I understand that I can cancel the product / membership at any time and incur no further charges. I agree to notify the merchant in writing of any changes in my account information or termination of this authorization 15 days prior to the net due date of the charges.

I likewise certify that I am the authorized user of the Credit Card that shall be submitted through this form. I understand that cancellations must be made in writing and as long as the transactions correspond to the terms and conditions indicated in this authorization, I shall not raise disputes against the company.

Card Type*

MasterCardVisaDiscoverAmerican Express

Card Number*

Credit Card Number

Expiration Date

Security Code

Bank Name*

This is an authorization to allow the Third Party Administrator to regularly charge my account the membership fee indicated on this form on a monthly basis. This agreement and the coverage shall remain in effect until I request cancellation or termination.

I understand that I can cancel the product / membership at any time and incur no further charges. I agree to notify the merchant in writing of any changes in my account information or termination of this authorization 15 days prior to the net due date of the charges.

I likewise certify that I am the authorized user of the bank account that shall be submitted through this form. I understand that because this is an electronic transaction, these funds will be withdrawn from my account as soon as the scheduled transaction date. I acknowledge that the orignation of ACH transactions to my account must comply with the provisions of US Law. I understand that cancellations must be made in writing and as long as the transactions correspond to the terms and conditions indicated in this authorization, I shall not raise disputes against the company.

Routing Number:*

Account Number:*

Account Type*

CheckingSavings

Check Type*

IndividualBusiness

Signature*

Date

Tell us about yourself

Spousal Information

Child Information

Choose your coverage

TOTAL:

Recurring Credit Card Authorization Form

Recurring ACH / Bank Draft Authorization Form