310 MARKET ST KINGSTON, PA 18704 Agreement # ___________ Date: ___________ Agreement Type: ___New____ Previously existing MEMBERSHIP AGREEMENT First Name Last Name Middle Initial Date Of Birth Street Address City State Zip Code Primary Phone Number Secondary Phone Number Drivers License Number Employer Occupation Email Address Contact Person Emergency Contact Number Emergency Contract Relationship MEMBERSHIP INFORMATION TERMS OF AGREEMENT The initial term of this agreement shall run for______ month (not to exceed 24 months) from the day and date above written unless otherwise modified pursuant to the termination, cancellation or tolling provisions contained elsewhere herein. Enrollment Fee ______________________ Balance Due ______________________ Monthly Fee ______________________ Monthly Installment Fee Amount ______________________ Membership Start Date ______________________ Payment Type ______________________ Membership End Date ______________________ Account Owner ______________________ Total Cost of Membership ______________________ Account Number ______________________ Paid Today ______________________ Account Expiration ______________________ DUES Membership dues shall be in the amount set forth under “MEMBERSHIP INFORMATION”, above. Elite Gym & Family Fitness Center shall not increase membership dues without first providing members 30 days written notice and/or by physically posting 30 days advance written notice within the club itself. The member understands that monthly membership dues are based on sales tax rates at the time of this Agreement, and to the extent such rates change, the club has the right to immediately adjust monthly membership dues and/or pre-authorized electronic funds transfers accordingly. New members to this gym are subject to a registration fee. A six month membership carries a $35 per month registration fee, a one year contract carries a $30 registration fee and our two year membership registration fee is waived. Elite Gym & Family Fitness Center also charges an annual $20 membership maintenance fee. This fee is to repair and buy new equipment and ensure your safety in our facility. TIMELY PAYMENTS Should The Member default on any payment obligation as called for in this Agreement. The Member agrees to pay 1 ½% monthly interest and all costs of collection, including, but not limited to, collection agency fees, attorney fees and court costs. A default occurs when any payment due under this agreement is more than ten (10) days late. SHOULD ANY PAYMENT BECOME MORE THAN TEN (10) DAYS PAST DUE THE MEMBER SHALL BE CHARGED A LATE FEE OF $10.00. FURTHERMORE, THE MEMBER SHALL BE CHARGED AN ADDITIONAL SERVICE FEE OF $15.00 FOR ANY CREDIT CARD OR ORDER RETURNED FOR INSUFFICIENT FUNDS OR ANY OTHER REASON. The Member is paying for their membership via electronic funds transfers (EFT), the club’s billing company, Palm Beach Financial Service, reserves the right to draft via EFT all amounts owed by The Member including any and all late fees and service fees, subject to appropriate state and federal laws. MEMBER’S RIGHT TO CANCEL If you wish to cancel this contract, you may do so by delivering or mailing by certified mail, return receipt requested, written notice to this health club. The notice must say that you do not wish to be bound by the contract and must be delivered or mailed before 12 midnight of the third business day after you sign and receive a copy of the contract. The notice must be delivered or mailed to: Elite Gym & Family Fitness Center, 310 Market Street, Kingston, PA 18704. In some cases you may also cancel this contract if you signed it before the health club facility was completed, if the club moves or goes out of business, if you become permanently disabled or move from the area. If you cancel, the health club is entitled to a certain portion of the contract price. There is a one month ($35) cancellation fee for our six month membership, three month ($90) cancellation fee for our 1 year contract and a six month ($150) cancellation fee for our two year contract. Members prior to August 1, 2013 who signs up for a new contract are not subject to a cancellation fee. If the health club goes out of business or refuses to give you a refund, there may be abound or letter of credit under which you are entitled to collect. For details, you should read your contract carefully. Enforcement of the Health Club Act is by the Attorney General of the Commonwealth of Pennsylvania or the district attorney of the county in which the health club is located. You may also bring a private cause of Pennsylvania or the district attorney of the country in which the health club is located. You may also bring a private cause of action. If your rights are violated, you may contact the state Bureau of consumer Protection or the local district attorney. All health club contracts used the following statement: “Under this contract, no further payments shall be due to anyone, including any purchaser of any note associated with or contained in this contract, in the event the Health club at which the contract is entered into ceases operation and fails to offer a comparable alternate location within ten miles.” All payments due under the contract are in equal monthly installments spread over an entire term of the contract, except that a club may charge and collect at the beginning of the contract, an initiation fee, not to exceed the lesser of six monthly installments to be made under the contract, or the actual costs of establishing the initial Health Club membership. Notice: Any holder of this contract is subject to all claims and defenses which the Debtor could assert against the seller of goods and services obtained pursuant hereto or with the proceeds hereof, recovery hereunder by the Debtor hereunder. Subsequent cancellation: During the Term of this Agreement and following the third business day after the Member signs this Agreement, the member may cancel this Agreement by delivering or mailing by certified mail, return receipt requested, at least Forty Five (45) days prior to cancellation, written notice of cancellation to: Elite Gym 310 Market Street, Kingston, PA 18704. I, the member, received an exact, fully complete and executed copy of this agreement, read and understand the terms & disclosures contained herein, including those on the reverse side and signed it this date_____. ____________________________________ CLUB REPRESENTATIVE ____________________________________ MEMBER ____________________________________ PARENT OR GUARDIAN REQUIRED FOR ALL EFT & CREDIT CARD DRAFT ACCOUNTS PLEASE ATTACH A VOID CHECK REQUEST FOR PREAUTHORIZED PAYMENT Payment Method: _______________ Check:__________________________________________________________________________________________________________________ CARD OWNER BANK NAME ROUTING NUMBER (9 DIGITS) ACCOUNT TYPE Credit/Debit:_____________________________________________________________________________________________________________ CARD OWNER BANK NAME ACCOUNT NUMBER EXPIRATION DATE CVV/CVC (3 digits on back) Subject to the following conditions: 1. The items shall be drawn on or about the date or dates of the Payment Schedule. The transactions on your bank statement will constitute receipts for payment on your account. 2. If the regular payments set forth on the Payment Schedule should vary in amount, you are entitled to notice at least 10 days before each payment of when it will be made and how much it will be. However, by expecting this preauthorization, you choose to instead get this notice only when the payment would differ by more than $150 from the most recent payment. 3. By executing this agreement, you acknowledge your awareness that certain disclosures required by the Electronic Funds Transfer Act and its regulations. 4. The Privilege of making payments under this arrangement may be revoked by the company if any item is not paid upon presentation 5. If this preauthorization payment agreement is revoked for any reason, this does not release you from your obligation (Payment Schedule). 6. A service fee will be assessed and drafted for any check, draft, credit card, or order returned for insufficient funds or any other reason. A late fee will be assessed and drafted should any monthly payment become past due. 7. This preauthorization payment arrangement shall apply to the following Applicant(s): Date: _____________ Customer Signature: ____________________________________ (Signature only required if name on account is different than member)