HealthQuest ACH/EFT Authorization
Name
First Name
Last Name
Type of Account
Checking
Savings
Bank Information
Must be either a checking or savings account at a bank institution
Bank Name
Routing Number
(9 digits)
Account Number
Select type of membership you are purchasing
6-month single membership ($32.90/month for 6-months; includes sales tax)
6-month family membership ($43.60/month for 6-months; includes sales tax)
Bank Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Notes:
By signing this form, you acknowledge that after your membership contract expires, automatic withdrawals will continue until you provide written notice to cancel your membership. This allows your membership to continue without the need to sign a new contract. This form of payment, if discontinued, does not release you from your payment obligation or membership contract.
Signature
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Bank Name
Should be Empty: