EFT Bank Authorization Form
In completing this form, you are authorizing UNICUS Fitness to debit your checking/savings account in the amount of $135 for the number of months selected below. Debits will be made on or around the 1st or 15th of each month (you choose below). A minimum of 3 months on Electronic Funds Transfer (EFT) is required to get the $135/month rate. Accounts that are canceled prior to the 3 months will incur a $150 fee. **Payments will be processed on the first of the month.

  First Name:
  Last Name:
  Address:
  Email Address:
  Phone Number:
  Bank Name:
  Account Type:
  Account Number:
  Bank Routing Number:
  Which Program Are You Enrolling In?:
  Select Your Start Date:
  Enrollment Length:

After filling the details click on the SUBMIT button.
 
 
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