Sign Up for AutoPay Checking Today

AutoPay Checking or credit card Authorization:(1) I authorize In-Shape Health Clubs, LLC (“ISHC”) to initiate an Electronic Funds Transfer (“EFT”) from the bank account listed above on a monthly basis (on or about the same day each month) for the recurring monthly fees and any other amounts I owe under my membership contract; (2) This authorization will remain in effect until my membership contract is canceled by ISHC or me in accordance with its terms. After a notice of cancellation is submitted by me, I authorize ISHC to continue to initiate EFTs for any amounts I owe which accrue through the date the cancellation becomes effective, until the balance due on my account is $0. The closing or termination of my bank account or cancellation of AutoPay does not cancel my membership; (3) I acknowledge that the monthly recurring fees may vary, and I have the right to have ISHC send me a written notice 10 days prior to the scheduled date of transfer when a regularly recurring EFT will vary in amount from the previous transfer. I also have the option to receive such notice only when a transfer will fall outside a specified range of dollar amounts. At this time, I agree that I am requesting that ISHC provide me with at least 10 days advance notice only if a recurring transfer will be more than three times my usual recurring monthly fees; (4) If my EFT is returned to ISHC unpaid, I authorize ISHC each time such event occurs to initiate a one-time EFT transfer, and collect a returned item fee of $7.00; and (5) I authorize ISHC to update my bank account information, and initiate EFTs therefrom, based on any Notification of Change of account number or routing number provided by my financial institution.

______________________________________ ___________________________________________Name (Please Print Clearly) Address ______________________________________ ____________________________Email Address Keycard Number/Membership Number

______________________________________ ____________________________Print Name of Lead Member Member Phone Number ______________________________________ ____________________________Authorized Signature Required for Processing Date

I’ve recently updated my information.

Routing Number(Must be 9 digits)

AutoPay Authorization:Yes, I would like my recurring monthly membership fees that become due under my membership contract to be charged to my checking or savings account, or credit or debit card. I have included a voided check or savings statement if choosing AutoPay ACH as my preferred method of payment.

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9853874745

DATE

PAY TO THE ORDER OF

DOLLARS

FOR MP

Security Features on Reverse

$

Payment Options: Pay by mail:Please write membership account in the memo section and make payable to:In-Shape Health Clubs 6. S El Dorado St. Ste. 600Stockton, CA 95202

Pay by Phone: (877) 446-7427

Pay at my local gym: To find the nearest gym, call: (877) 446-7472

Account Number(Up to 15 digits)

Card Name: Visa, MasterCard, Discover, or American Express(Circle One)

Card Type: Debit / Credit(Circle One)

Card #: - - - Exp. Date

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