Auto Pay Application

"*" indicates required fields

Billing Address of Cardholder*

Card Type*
This is to certify that Junior Gym has my permission to automatically charge my card for: (check all that apply)

By clicking the SUBMIT button, I am electronically signing this application for Auto Pay. I hereby, authorize Junior Gym to charge my credit card. I UNDERSTAND IT IS MY RESPONSIBILITY TO NOTIFY JUNIOR GYM TO BE REMOVED FROM AUTOPAY 5 DAYS PRIOR TO CHARGE DATE*
MM slash DD slash YYYY