Direct Debit

Trainer's Name*

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Payment Instruction

IMPORTANT: Fees and charges may apply. Please allow 5 working days for processing after the form is received by Ezypay.

to be debited every month starting on*

Agreement end date*

Options*

$30 per week on 12 month agreement total cost $1560
$35 per week on 6 month agreement total cost $910
$38.07 per week on 3 month agreement total cost $456.84
$195 per month - Month To Month Agreement
Kids - 12-15yrs old - $25 per week on a 12 month agreement total cost $1300
Kids - 12-15yrs old - $30 per week on a 3 month agreement total cost $360
Kids - 12-15yrs old - $35 per week - Month to Month Agreement minium total cost - $140 (1 month)

START PACKS COMPULSORY*

Raw Pack $99 1x PT, 1x Wraps and 1x F2B t-shirt
Ali Pack $129 1xPt, 1x Wraps, 1x F2B t-shirt and 1x Boxing Gloves

These payments are all Direct Debit from an account monthly on the 1st or 15th of each month. After agreement is finished payment will continue unless cancelled.

Direct Debit Agreement*

By ticking this box I acknowledge that my direct debit will not be canceled automatically at the end of the agreement. To cancel the direct debit you will need to send through a written cancellation via email. Your monthly payments will continue as per agreed amount and date unless otherwise notified in writing.

Payment Method (Select One)*

1. BANK ACCOUNT

Name of Institution*

BSB*

ACCOUNT*

Name of Account Holder(s)*

Branch Location*

2. CREDIT CARD

Card Type*

Visa
Mastercard

Card Number*

Expiry Date (mmyy)*

Name on card*

 ONLINE STORE NOW AVAILABLEE

Payment Instruction

1. BANK ACCOUNT

2. CREDIT CARD

Cancellation (Terms and Conditions)

AUTHORISATION

BY COMPLETING PAYMENT DETAILS, YOU AGREE TO BE BOUND BYT THE TERMS AND CONDITIONS STATED ABOVE