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
Kick Start 2021 $0 1xPT, 1x wraps, 1x F2B T or Singlet,1x 120z Sting Gloves & 1x Month Unlimited groups

These payments are all Direct Debit from an account monthly on the same date as your start date for the entire agreement. After agreement is finished payment will continue unless cancelled.

Direct Debit And Kick Start 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.
By ticking this box and singing up to our $0 Kick Start program I agree that if I discontinue for any reasons other than medical before the 6 or 12 months. I will be required to pay the full amount of the starter pack value $275 and the remaining membership price for the remaining months.

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