VBRC Client Enrollment

Name of Subscriber (Facility Operator)*

Facility Name*

Number of Club's Enrolling*

Facility Street Address*

Facility City, State and Zip*

Contact Information

Facility Phone*

Cell Phone*

Fax Number

Email Address*

Billing Address

Facility billing address, if different from facility address.

Billing Address

Billing City, State and Zip

Business Status

Business Status 1

Corporation Proprietor Ltd Partnership Partnership LLC

Other

Agreement

YES, we agree to participate in the Fitness Club Success, LLC (FCS), Virtual Business Resource Center Client Program.

We agree to pay FCS a one time set up fee of

plus

on a

12-Month Agreement Month to Month Agreement

Following the final month of the subscription period we understand that our agreement will continue on a month to month basis.

Cancellation must be made with 30 days written notice via certified mail at any time following the first day of the final month of the chosen subscription term.

FCS reserves the right to annual dues increase of no more than 4% to keep pace with inflation.

First and last month subscription fee is required for initial set-up.

Subsequent monthly dues payments must be made by Electronic Funds Transfer (EFT). The authorized account will be debited on either the 1st or 15th of each month.

All FCS artwork and promotional copy is copyrighted and the property of FCS and we agree not to use it outside of this agreement.

FCS promises to provide the services and accessibilities as outlined in this agreement. FCS shall not, without prior written consent of the Client, disclose to anyone any confidential information.

Confidential information is any information disclosed to FCS that is NOT publicly available, disclosed byClient without restriction, or rightfully received by FCS from a third party.

Both parties agree to abide by the terms of this agreement.

In the event an account balance is past due (funds not collected during the month amounts are billed), the account will be charged a fee of $50 per each arrears month.

There will be a penalty charge of up to $25 for each returned debits/items.

If legal action is taken to enforce the terms of this agreement, the undersigned subscriber agrees to pay all reasonable legal fees and costs of collection to the extent permitted by law.

This agreement is governed by the laws of Arizona and the home state of the subscriber.

Agreement Authorization

Yes, I agree with the terms of this agreement.
No, I do not agree with the terms of this agreement.

Initials of Authorized Agent*

Payment Account Information

I authorize my bank to make automatic payment to Fitness Club Success by the method indicated below and in accordance with this agreement.

Credit or Debit Card Checking Account

Preferred Debit Date

1st of the Month 15th of the Month

Credit or Debit Card Option

Only complete this section if the Credit or Debit card payment optiion was chosen.

Card Type

Master Card
Visa
American Express
Discover

Card Number

Expiration Date (MM/YYYY)

Security Code

Checking Account Option

Only complete this section if the Checking Account Option was chosen.

Bank Name

Bank Address

Bank City, State and Zip

9-Digit Routing Number

Account Number

Special Instructions