Authorization for Monthly Recurring Credit or Debit Card Charge I by huangyuarong

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									Payment Authorization
                                                                            a KMK Company of Illinois membership facility




AUTHORIZATION FOR MONTHLY RECURRING CREDIT OR DEBIT CARD CHARGE
I hereby authorize myTRAINER to charge my credit or debit card on a recurring monthly basis for amounts
I may owe, all in accordance with my Membership Agreement and/or my Facility Usage Agreement
currently on-file. This authorization is valid only until such time that the agreed-upon membership services
terminate or until such time that I choose to terminate or otherwise revoke this authorization. Unless
otherwise noted in writing, this authorization is for the limited use of paying my monthly membership dues
at the agreed-upon monthly rate and accompanying bank or account processing fees, if any. I agree to
notify myTrainer of any changes to my credit or debit card account information.


        Member’s name __________________________________________________________

        Cardholder’s name (if different) _______________________________________________

         VISA _______      MasterCard _______      Discover _______ American Express ______

        Card number _____________________________________________________________

        Expiration date ___________________________________________________________

        CVV2 security code ________________________________________________________

        Billing address ____________________________________________________________

        City/State/Zip _____________________________________________________________


        Signature _________________________________________

        Date _____________________________________________




                         332 Skokie Valley Road ▪ Highland Park ▪ Illinois 60035
                                Office 847.780.4421 ▪ FAX 847.780.4542
                                          www.myTRAINERhp.com

								
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