PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

2022 Partnership Commitment Form

Member Information

* First Name

* Last Name

* Address

* City, State, Zip

* Phone Number

* 2022 Partnership Commitment Amount

2022 Security & Technology Fee: $100

* TOTAL AMOUNT

Payment Information

* Payment Method

	I will mail a check to United Hebrew
	Stock Transfer - We will contact you about this option
	ACH - Please complete the information below
	Debit or Credit Card- - Please complete the information below

* Payment frequency:

Number of Payments

Amount per payment:

Date for payments to begin:

Bank Rounting Number

Account Number

Name on card

Card Number

Expiration Date

CVV - Code on the back of your card

*E-mail

*First Name

*Last Name

Account

Online Fee:

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Total: