---

  Member Information

* Name:
* Phone:
* Email:

Adress 1:
Apt/Suite:
City:
State:
Zip:

  Billing Information
    the name and address of the billing information must match the information on the account you are using

* Name on Card:
* Adress 1:
* Apt/Suite:
* City:
* State:
* Zip:

  Card Information

* Payment	Choose Visa Master Card AMEX
* Card Number:
* Expiration Date:

 

  Optional Information

Have you been in Club Ex in the last 14 days for a tour of the facility with one of our fitness coordinator’s?	Yes:    No:
If yes, then who?
When is a good time to call you to set up an appointment with a personal trainer and a tour if you haven’t already had one?	AM: PM:
Phone number to reach you at:
How did you hear about us?	TV Radio Newspaper Website Drive-by Friend Other
If 'OTHER' then how?
I am authorizing Club eX to use the above account information for my monthly draft payments. If I want to use a different account I will change it at the gym. I understand I will give 30 written notification to stop my membership.	Yes:    No: