Name * First Name Last Name Date * MM DD YYYY Membership # Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Add-Ons * Classes Tanning Personal Training None Tanning Pin Code If applicable Initiation * $35 1st Month * $35 Add-Ons $ Total Due * $ Payment Method * Cash Card Check Bank Account & Routing Numbers / Credit Card Number * Reoccurring payments will be billed monthly for a minimum of 12 months on or around the 10th day of the month. Expiration Date (If Applicable) MM DD YYYY CVC (3 Digit Code / If Applicaple) Terms and Conditions * I have read and agree to all terms and conditions of this membership Signature * By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature. Thank you! Terms & Conditions
