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For Enrollment in AutoPay. 

Recurring Credit/Debit Card Payment Authorization Form

I authorize the Artistic Gymnastics Institute LLC (AGI) to make recurring charges in the amount designated below to my Credit/Debit Card listed below, and if necessary, to initiate adjustments for any transactions credited or debited in error. This authority will remain in effect until AGI has received written or email notification to cancel it. Notice must be received by AGI before the last business day prior to the recurring charge date in order to cancel the next payment. Further, I understand that non-attendance, non-participation or weather-related gym closures do not constitute a cancellation or suspension of this authorization nor does it entitle me to a refund, full or partial. Should I dispute a charge through my financial institution this will constitute a breach of contract possibly resulting in, but not limited to, penalties, additional fees, collection, legal action, and/or termination of any and/or all current and future services.

First Auto Pay Customer Name

First Name*

Last Name*

Phone*
First Auto Pay Customer Date of Birth*
I certify that I am 18 years of age or older
First Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
First Auto Pay Customer Signature*
Second Auto Pay Customer Name

First Name*

Last Name*
Second Auto Pay Customer Date of Birth*
Second Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Third Auto Pay Customer Name

First Name*

Last Name*
Third Auto Pay Customer Date of Birth*
Third Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Fourth Auto Pay Customer Name

First Name*

Last Name*
Fourth Auto Pay Customer Date of Birth*
Fourth Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Fifth Auto Pay Customer Name

First Name*

Last Name*
Fifth Auto Pay Customer Date of Birth*
Fifth Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Sixth Auto Pay Customer Name

First Name*

Last Name*
Sixth Auto Pay Customer Date of Birth*
Sixth Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Seventh Auto Pay Customer Name

First Name*

Last Name*
Seventh Auto Pay Customer Date of Birth*
Seventh Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Eighth Auto Pay Customer Name

First Name*

Last Name*
Eighth Auto Pay Customer Date of Birth*
Eighth Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Ninth Auto Pay Customer Name

First Name*

Last Name*
Ninth Auto Pay Customer Date of Birth*
Ninth Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Tenth Auto Pay Customer Name

First Name*

Last Name*
Tenth Auto Pay Customer Date of Birth*
Tenth Auto Pay Customer Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Billing Address

Address *

City *

State *

Zip Code *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Select Card Type *
Visa
Discover
Mastercard

Card Number *

Expiration Date *

CVC Code *

Enter Recurring Charge Amount in $0.00 format. *
I authorize my card to be charged on a monthly recurring basis, on the last business day prior to the due date as selected below:*
1st
10th
20th
I authorize my card to be kept on file to be charged for one-time transactions.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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