Credit Card EFT Form

Credit Card Authorization Form
In completing this form, you are authorizing UNICUS Fitness to charge your credit card in the amount of $135 for the number of months selected below. Charges will be made on or around the 1st or 15th each month (you choose which date is best for you). 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. All payments will be processed on the first of the month.

*indicates required fields

*First Name:

*Last Name:

*Address:

*Email Address:

*Phone Number:

*Credit Card Type:

*Credit Card Number:

*Expiration Date:

*3 Digit Code:

*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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