ECard Charge Application

Please complete the following application in its entirety to be eligible for a New Leaf Community Markets, Inc. ECard charge account.New Leaf Community Markets, Inc. partners with Bank of America to process ACH transactions and will never disclose personallyidentifiable information to any other party. Your account will be charged upon submitting an order. We only accept bank checkinginformation as a form of payment.

Once complete mail, fax, or email application to:

New Leaf Community Markets, Inc.

Attn: Ecard Program1101 Pacific Avenue, Suite 333

Santa Cruz, CA 95060

F: 831.466.0925

E: Ecard@newleaf.com

School Name*

School Tax ID/EIN*

Coordinator First Name*

Coordinator Last Name*

Coordinator Phone Number*

Coordinator Email*

Coordinator Mailing Address*

Account Type*

Checking/Savings

Bank Name*

Name on Account*

Account Number*

Routing/ABA Number*

9 Digits

Application Agreement*

Applicant has carefully reviewed this application and confirmed that all information is true and correct. Applicant agrees to pay e‐ transaction upon delivery of order. An email copy of receipt will be received upon charge of account. Applicant’s signature indicates complete agreement to terms, and holds applicant responsible for any outstanding balances. Furthermore, applicant understandsthat failure to pay balance indicates delinquency, at which time the account will be closed permanently and collection procedures will follow.*

Applicant Full Name*

Today's Date*