Payment Authorization

Card Holder Name(Required)

First Last

Card Holder ID(Required)

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Credit Card Number(Required)

Card Expiration Date MM/YY(Required)

CVV Security Code(Required)

Name of Account for Payment Authorization(Required)

First Last

What Member are you authorizing payment for?

Date of Birth For The Above Person(Required)

Payment Amount(Required)

1 Year EFT Contract ($55 Per Month)

1 Year Sunshine EFT Contract ($35 Per Month)

Other

Payment Authorization(Required)

You authorize regularly scheduled charges to your credit card or bank account. You will be charged the outstanding amount each billing period. You agree that no prior notification will be provided unless the amount changes

I authorize this card to be charged for all outstanding balances for the above person per the terms of the contract

Guarantee(Required)

I agreed to be fully responsible for the outstanding balance of the above party listed in this agreement within the terms of the contract. This agreement expires 1 year after submission.

I agree to Guarantee the balance of this membership

Signature(Required)