e-Check

1. Today's Date
Dia de Hoy *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

2. I've authorized UHA to debit my banking account listed bellow on today's date
for the amount of :

Autorizo a UHA a cargar mi cuenta bancaria a continuación en la fecha de hoy
por la cantidad de

*This question is required. This question requires a valid number format.

3. If recurrent Payment, please please indicate how many recurrent payment have you authorized ?

Si el pago es recurrente, indique cuántos pagos periódicos ha autorizado

4. My Account Information is as Follows; *This question is required.

Customer Name;

Bank Name

Bank Account Type ( checking , savings , business)

Bank ABA ( routing Number, 9 digits) This question requires a valid number format.

Bank Account Number This question requires a valid number format.

5. Please complete form

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address

Mobile Phone

6. The product or service acquired is :

El producto o servicio adquirido es ;

*This question is required.

8. Customer signature acknowledges receipt of goods in the amount of the total shown in item number 2 and recurring payments
hereon and agrees to perform the obligations set forth by the customer's agreement with the issuer.
This authorization is valid Unless the undersign notify UHA of its cancelation by sending a written Notice to mail@uhaglobal.com
or contact our main Phone Number at 1800-506-4521

La firma del cliente reconocen la recepción de bienes por el monto del total indicado en el número de artículo 2 y pagos mensuales
Y se compromete a cumplir las obligaciones establecidas por el acuerdo del cliente con el emisor.

Esta autorización es válida a menos que el suscrito notifique a UHA de su cancelación enviando un aviso por escrito a mail@uhaglobal.com
o comuníquese con nuestro número de teléfono principal al 1800-506-4521

*This question is required.

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