ACH Enrollment - TWO PEAKS FITNESS

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Two Peaks Fitness Inc
PO Box 905
La Veta CO 81055

Authorization Agreement for Preauthorized Electronic Payments

I heareby authorize Two Peaks Fitness Inc to initiate debit/credit entries to my Checking/Savings account indicated below at the depository (Bank or Credit Union) named below, to credit/debit the amount to such account for the purposes of payments to Two Peaks Fitness Inc.

Location (choose one)

Member Name

First

Last

Monthly membership amount to debit

Minimum Price: $15.00

Beginning on

Financial Institution Name

City

State

Routing Number (9 digits)

Account Number

Account Type

Name(s) on Account

I understand that if an erroneous debit/credit is made to my account Two Peaks Fitness Inc and the financial institution are authorized to reverse the entry and make any adjustments necessary to my account to correct the erroneous entry. This authorization is to remain in full force and effective until Two Peaks Fitness Inc has received notification from me of its termination in writing and at least 10 days prior to the next billing date (first day of the following month); this is to afford Two Peaks Fitness Inc and the depository (Bank or Credit Union) institution reasonable opportunity to act on it.

Name

Signature

Clear Signature

Date of authorization

This institution is an equal opportunity provider and employer.

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