Electronic Check Authorization Form - HealthSmart Botanicals

E-Check Authorization Form

Please complete the following form to authorize an electronic check payment.

Name On Check*
Address*
Street Address Address Line 2 City State ZIP Code
Bank Routing Number*
Bank Account Number*
Account Type*
- Checking
- Savings
Invoice Number
Amount Authorized
Email For Receipts
Authorization*
I agree to the terms below.
By submitting this form I hereby authorize HealthSmart Botanicals, LLC to debit the account listed above in the agreed upon amounts.

FDA Disclosure

These statements have not been evaluated by the FDA and are not intended to diagnose, treat or cure any disease. Always consult with your physician before use. These statements do not guarantee same results as Advertised. 18 + ONLY. The Cannabidiol in HealthSmart Botanicals products is a natural constituent of the industrial hemp plant. HealthSmart Botanicals does not sell or distribute any products that are in violation of the United States Controlled Substances Act (USCSA).

Hemp Derived. Non-Detectable THC or Less than 0.3% THC.

E-Check Authorization Form

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