Westmount: Express Club 12M JOL

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

Bi-Weekly Payment

$13.60

$0.00

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Enrollment	$0.00	$0.00	$0.00	0
Membership Dues	$0.00	$12.95	$12.95	0
Sub-Total	$0.00	$12.95
Tax	$0.00	$0.65
Total	$0.00	$13.60

Payments will then be processed on a Bi-Weekly basis there after.

Card Fee (Per member) of $29.00 will be billed on a One-Time basis starting 4/26/2024

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