The Energy Club: Ultimate 12 Month

Primary Member Information

First Name

M.I.

Last Name

Address 1

Address 2

City

State / Province

Zip / Postal Code

Home Phone

Mobile Phone

OK to Contact Home Phone

OK to Contact Mobile Phone

Preferred Phone

Home

Mobile

OK to Contact Email?

Birth Date

Gender

Male Female Other

Add-Ons for this member

Locker Monthly Draft

$10.00 down $10.00 / month

Monthly Payment

$39.00

$11.50

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Dues - Membership	$0.00	$39.00	$39.00	0
Scan Card Fee	$10.00	$0.00	$0.00	0
Credit Card Fee	$1.50	$0.00	$0.00	0
Sub-Total	$11.50	$39.00
Tax	$0	$0.00
Total	$11.50	$39.00

Payments will then be processed on a Monthly basis there after.

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