Automatic Payment Enrollment Form
Yoga Health Center, 636 El Camino Real, San Carlos, CA 94070 (650) 631-YOGA (9642)
www.yogahealthcenter.com
PLEASE PRINT:
YOUR NAME: _____________________________________________________________________________
ADDRESS ________________________________________________CITY_____________________________
STATE ______ ZIP____________ CELL (_____)__________________HOME (_____)___________________
Terms of Auto Monthly: (Please indicate agreement by initializing each line)
______ I understand I will be charged $79 or $89 per month, (12 or 6 months agreement) plus $39 payment upon activation
______ I agree to the one time $39 set-up fee
______ I understand this is either a __12 month or___6 month minimum membership contract. (Check one)
______ I authorize a $20 payment for any insufficient check/credit card fees.
______ I understand that this agreement will continue month to month after the 6 or 12 months or until canceled by mail
to the Yoga Health Center or email to regina@yogahealthcenter.com
Terms of Auto Monthly Termination:______ I understand that a 30 day written or email notice is required in order to terminate my auto monthly enrollment
beginning in month 6 or month 12. (Circle one)______ I understand if I cancel before the expiration of my agreement there is a 3 month cancellation fee for the
12 month agreement and a 2 month cancellation fee for the 6 month program. My cancellation must be
communicated by mail to the Yoga Health Center or emailed to regina@yogahealthcenter.com. There is no cancellation fee
after the original 6 or 12 month agreement.______ I understand that my last payment will be charged on my regular payment date within 30 days of receipt of mailed
notice to Yoga Health Center or emailed to regina@yogahealthcenter.com.
I understand and agree to all terms above Date: __________________________
Print Name:___________________________________Signature_______________________________
Authorized Signature
CREDIT CARD INFORMATION ( VISA, M/C )
Name on Credit card ___________________________________________________________________
Credit Card # VISA / MC (Circle one) (Sorry, we do not accept AMEX)_________________________________________________
Exp. Date:________________________ Code/Vin#:__________ (3 digit code on back for VISA/MC)
For Office use only: Start Date _______________________ Set-up Fee _____________________________
Debit Date 1st or 15th First month ___________________Total _______________