Water Filtration System Order Form

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Application for Water Filtration System

To order your Water Filtration System through Fingerlakes Quantum Health, read the following information pertaining to the application and then fill in the form below and submit it to me. I will, in turn, place your order through RichWay for you. If you have any questions concerning the application, please feel free to contact me.

Applicant Information

*Social Security and any other information will be kept confidential. RichWay International will use this information only for credit-check purposes.

Order Information

Lease-to-Own (2 1/2 YEAR PROGRAM) $299.95 down payment. Customer owns the produxt after 30 monthly installments. Sales tax (4.712%) will apply to Hawaiian residents. Total investment to OWN $1,498.95.
FIRST PAYMENT $299.95 / MONTHLY PAYMENT $39.95 / 30 months.

Rental Plan (3 YEAR PROGRAM) $79.95 processing and enrollment fee. Concluding the rental period, the customer has the option to own the equipment ($300.00). Otherwise, the product must be returned, shipping paid by RichWay. Additional sales tax (4.712%) will apply to Hawaiian residents. Total Investment to Own $1,818.15. FIRST PAYMENT $79.95 / $39.95 / 36 MONTHS.

*RichWay International does not ship to P.O. Box addresses. Orders must be shipped to the credit card holder. If the billilng and shipping are different, please attach additional details.

Credit Card Information

*RichWay International will make charges to your credit card based on the installment plan you select. It is the consumer's responsibility to keep up to date with his/her credit card info.

* Required fields

Name *

E-mail Address *

Select the program you wish to enroll in. *
Lease-to-Own (2 1/2 year program)
Rental Plan (3 year program)

Address (street) *

Address (city) *

Address (state) *

Address (zip code) *

Address (country) *

Social Security # (ex. xxx-xx-xxxx) *

Date of Birth (ex. mm/dd/yyyy) *

Phone number including area code (xxx) xxx-xxxx *

Credit Card Type *

Credit Card Number *

Expiration Date (ex. mm/yy) *

CCV (Approval Code) (last 3 digits on back of credit card) *

Credit Card Holder's Name (as it appears on the credit card) *

Authorized Initials - By initialing, I authorize RichWay International to charge my credit card the initial amount for the plan selected. Monthly installments will be charged every 10th day following enrollment. *

Billing Address (if different from above address) Please be sure to include street, city, state, zip code, and country

I have read and agree to the Privacy Policy *

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