Membership Billing Request Form

Membership Billing Request Form

Use this form to sign up for our discount rates, billed fortnightly, monthly, or quarterly via invoice, and paid via cash, PayPal, or bank transfer.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area Code (+61 for mobiles)Phone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What do you wish to do?*

Sign up for a discount membership optionPause my current discount membership payments, until further notice, from the end of the current billing periodCease my discount memberships from the end of the current billing period
Which membership option do you wish to sign up for?*

TAGISA / UMA - Single Training Session Each WeekTAGDUHA / DUAS - Two Training Sessions Each Week
Are you a full-time student or concession card holder?*

YesNo
How often would you like to be billed for your Tagisa(Uma)-Standard-Membership?*

$30 Fortnightly ($15 / class)$60 Monthly ($15 / class)$180 Quarterly ($15 / class)
How often would you like to be billed for your Tagduha(Duas)-Standard-Membership?*

$25 Weekly ($12.50 / class)$50 Fortnightly ($12.50 / class)$100 Monthly ($12.50 / class)$300 Quarterly ($12.50 / class)
How often would you like to be billed for your Tagisa(Uma)-Concession-Membership?*

$25 Fortnightly ($12.50 / class)$50 Monthly ($12.50 / class)$150 Quarterly ($12.50 / class)
How often would you like to be billed for your Tagduha(Duas)-Concession-Membership?*

$20 Weekly ($10 / class)$40 Fortnightly ($10 / class)$80 Monthly ($10 / class)$240 Quarterly ($10 / class)
How would you prefer to pay for training?*

Cash PaymentPayPal (Online)Electronic Bank Transfer
Terms and Conditions*

I understand that I may stop or pause invoices (and payments), from the end of the current billing period, by resubmitting this form.
Why do you wish to pause or cease your discount membership payments? (Please indicate all that apply)

I wish to pay casually as I can only attend irregularlyMy work commitments are impacting on my ability to trainMy personal commitments are impacting on my ability to trainI have been injured, or have health conditions, that are impacting on my ability to trainI no longer have the time to trainMy interests have changedI would rather not sayOther
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

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