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ContractRegistration Form • November 14th, 2011
REGISTRATION FORM Name: ID No: Date of birth: Email: Phone: Current address: City: State: ZIP Code: Current employer: Employer address: Phone: Emergency Contact Name: Phone: CLASS TYPE Annual Agreement – paid monthly Month to Month Individual 2 person Family Date of draft 1st of the month 15th of the month Name ID No: Name ID No: Name ID No: Name ID No: PAYMENT INFORMATION EFT AuthorizationI, , authorize my bank to make my payment by the method indicated below and post it to my account. Checking (attach voided check) Visa Mastercard Discover Acct. no. Routing no. Bank name: Bank address: Bank phone: Credit Card Expiration date: CV Code: Signature Date Enrollment Fee Pro-rate amount Retail Tax TOTAL Default and Late PaymentShould you default on any payment obligation as call for in this agreement, the entire remaining balance shall be deemed due and payable upon demand, and you agree to pay allowable interest, and all cost of collection, including, but not limited to, coll
