Online Check Ordering Form

NOTE:
This option is only available to customers in the US and Canada.

Please use the following form to order all products when paying Online by Check. If you would prefer to pay Check by Fax, please visit the Fax Center for Ordering. Simply fill in this form completely. When finished, please Submit the form. By using the Check By Email option and the form below, you agree to the Terms and Conditions as set forth by this agreement

'*' indicates required fields

*Name:
*E-Mail:
Company:
*Street Address:
*City, *State, *Zip:	,
Shipping Address:	Only if different from above address.
Shipping City, State, Zip:	Only if different from above address. ,
Phone:	Preferred
*Items ordered:	Enter item numbers & short description below:
*Payment Type	Online Check
Online CHECK Info (USA only)
*Name On Check	("A" from above)
*Your Check Address:	("A" from  above)
*Your Check City, State, Zip Code:	("A" from  above)
*Bank Name:	("B" from above)
*Bank City, State & Zip Code:	("C" from above)
*Check Number:	("D" from above)
*A.B.A. Fraction:	("E" from above)
*Routing Number (9 Digits):	("F" from above)
*Account Number:	("G" from above)
*All Numbers From Bottom of Check: (see instructions below) This is redundant, but it will ensure accuracy.
Coupon Number:
Coupon Discount:
*Amount of Check:
By submitting this form, you are giving permission to draft your checking account in the amount listed in the form above. Any check returned for insufficient funds is subject to a $25 service fee. By typing my Full Name in this box,* I agree to these terms.

TERMS & CONDITIONS

I authorize Scot Brown to start an electronic check payment arrangement to pay for my order. I have read and agree to the following terms:

1. Scot Brown will process electronic checks against my bank account to pay for my orders. I will provide the check number for each purchase at the time of such purchase.

2. I agree to maintain sufficient funds in my account to cover said electronic checks.

3. In the event a check is returned for any reason, or in the event payment is stopped on any check, acceptance of any further orders may be refused until payment on such check is received. Note: a $25.00 processing fee will be charged on all returned checks.

4. I understand and agree that this authorization will remain in affect until written notification from me stating that I am revoking the authorization is received.

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The information contained herein is for educational purposes only. It is not medical advice and is not intended to replace the advice or attention of health care professionals. Consult your physician before beginning or making changes in your diet, supplements or exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications.

Copyright EnergyPlates.com © 2014

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E-mail: questions@energyplates.com
Fax: 1-623-321-9977
Order Toll-Free: 1-877-877-0747
15508 W. Bell Road Suite 101-438 | Surprise, Arizona [85374] | USA