| NAME:
_________________________________________________________________________ ...................First.......................Middle.......................Last ADDRESS: ______________________________________________________________________ _______________________________________________________________________________ PHONE: ________________________________________________________________________ ...................Home.......................Work.......................Cell PREFERRED METHOD OF PAYMENT: (please initial the blanks) ____ 1. I would like to come in and pay the balance from the 28th either by cash, check or debit by the 15th of the following month. (Note: A credit card # is still needed for this option. By initializing to the left of number 1, I understand that if I have not paid my balance due in full by the 15th of the next month my credit card will be billed for the amount due.) ____ 2. I would like for my credit card to be ran on the 28th of each month. CC#: __________________________________________________________________________ Type: _________________________________________________________________________ Expiration: ______________________________________________________________________ Authorization Signature: ___________________________________ Date: _________________ OTHERS ALLOWED TO USE HOUSE CHARGE: Please state member's full name and relationship to card holder. 1. _____________________________________ 2. _____________________________________ 3. _____________________________________ ------------------------------------------------------------------------------------------ CARD NUMBER: ________________________(for company use only) |