VIP Wellness Spa Membership Direct Debit Form

VIP Wellness Spa Membership Direct Debit Form
Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Membership
Please specify which membership you would like*

Silver Member - $35 per weekGold Member - $46 per weekPlatinum Member - $58 per week
Bank Details
Name on Card*
Account Type

VISAMASTERCARD
Amount to be debited weekly ($) each monday*
This is an authorization to debit the exact amount of from the account listed above. The said amount should be debited on each month as a ongoing charge until notified in writing to reception@summerelisabethdayspa.com giving 1 months notice. Payments are in calander months.

First Months will be charged in full on sign up

Silver $150, Gold $200 and Platinum $250
Signature*

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Date*

DayMonthYear
Date
Should be Empty:

Personal Information