Fitness Advantage: 1 Yr Monthly EFT w/contract

Primary Member Information

First Name

M.I.

Last Name

Address 1

Address 2

City

State / Province

Zip / Postal Code

Home Phone

OK to Contact Home Phone

Preferred Phone

Home

Monthly Payment

$75.00

$66.69

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Monthly EFT	$0.00	$75.00	$75.00	0
Monthly EFT	$66.69			0
Sub-Total	$66.69	$75.00
Tax	$0.00	$0.00
Total	$66.69	$75.00

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

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