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 Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code (+61 for mobiles)
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What do you wish to do?
*
Sign up for a discount membership option
Pause my current discount membership payments, until further notice, from the end of the current billing period
Cease 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 Week
TAGDUHA / DUAS - Two Training Sessions Each Week
Are you a full-time student or concession card holder?
*
Yes
No
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 Payment
PayPal (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 irregularly
My work commitments are impacting on my ability to train
My personal commitments are impacting on my ability to train
I have been injured, or have health conditions, that are impacting on my ability to train
I no longer have the time to train
My interests have changed
I would rather not say
Other
Date
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Submit
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