Contact Us Form

EFT Bank Authorization Form
In completing this form, you are authorizing UNICUS Fitness to debit your checking/savings account in the amount of $135 for the number of months selected below. Debits will be made on or around the 1st or 15th of each month (you choose below). A minimum of 3 months on Electronic Funds Transfer (EFT) is required to get the $135/month rate. Accounts that are canceled prior to the 3 months will incur a $150 fee. **Payments will be processed on the first of the month.

*indicates required fields

*First Name:

*Last Name:

*Address:

*Email Address:

*Phone Number:

*Bank Name:

*Account Type:

*Account Number:

*Bank Routing Number:

*Which Program Are You Enrolling In?:

*Select Your Start Date:

*Enrollment Length:

After filling the details click on the SUBMIT button.

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