SWET 12 Month Individual Membership Form

1

Name* This field is required

Prefix

First Name

Middle Name

Last Name

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2

Address* This field is required

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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3

Phone Number* This field is requiredPlease advise us of your best contact number

Area Code

Phone Number

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4

Date of Birth* This field is required

Date

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5

Email* This field is required

example@example.com

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6

Payment Frequency for 12 Month Contract* This field is requiredSelect your preferred payment frequency

Weekly: $40

Fortnightly: $80

Monthly: $173.33

4 Weekly: $160

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7

Debit Date* This field is requiredOn what date would you like your regular payments to start from?

Date

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8

What date would you like your membership to start from?Please be aware that your first payment will include any period of membership that pre-dates your initial direct debit payment.

Date

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9

Bank Details * This field is required

Bank account name

Bank Account Number from which payments to be made

Bank

Branch

Town/City

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10

Auto-renew* This field is requiredWould you like for your membership to automatically renew at the end of the minimum contracted period?

YesNo

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11

Emergency Contact Details* This field is required

Name

Relationship

Phone Number

Email address

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12

Profile PhotoFor identification purposes, we require a profile photo of you for your account. If you would prefer to take this yourself, please take this opportunity to do so now. Otherwise we're happy to take this for you in the gym.

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