Credit Card Authorization Form

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CREDIT CARD AUTHORIZATION FORM
Fitness Center Name:
Total Wellness Coaching LLC
Member ID #:
Member Name:
Date of first payment:
Date of last payment: (leave blank if not applicable)
st
Preferred payment date:
1
___
Amount of monthly payment: $_______
Last Name
First Name
Address
City
State
Zip
Email
Please debit payment from my (check one):
Routing Number: ______________________________
Valid Routing # must start with 0, 1, 2, or 3
Savings Account
(contact your financial institution for Routing #)
Account Number: ______________________________
Checking Account
(attach a voided check below)
I authorize the above company to process debit entries to my account. I understand that this authority will remain in effect
until I provide reasonable notification to terminate the authorization.
Authorized Signature:__________________________________________________________ Date:________________
Please charge my payment to my (check one):
Visa
MasterCard
Discover Card
Credit Card Number:
Expiration Date:
Name on Card:
Billing Address (if different from above):
I authorize the above company to charge my credit card in accordance with the information above.
Signature (as it appears on the credit card): _____________________________________________ Date: ____________
If using a checking account, please attach a voided check over the credit card section above.

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