Add Secondary Billing Source Order Number Member Information Date * MM/DD/YYYY Member Name * Name as it appears on Membership Agreement Scanner Card Number * Scanner Card Number Used to Check-In at Club Family Member(s) Changes will apply to all parties on a family membership Billing Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Primary Phone Alternate Phone Number Email * What is a Second Source? In the event that your Primary Source does not authorize payment on the requested due date, National Fitness Center can attempt to collect the payment amount from the second source. Second Source Payment Option Information Please indicate if you have more than one draft that you wish for this information to be used for, otherwise we will assume you wish to use if for your membership dues only. Membership Personal Training Locker Kids In Motion Name as it Appears on Credit Card * Credit Card Number * Credit Card Expiration * CVV Code * Additional Comments **A MINIMUM OF FIVE BUSINESS DAYS NOTICE IS REQUIRED FOR ANY CHANGES TO TAKE EFFECT** With less than 5 business days notice, we can not guarantee that your request will be processed in time for your next payment date; therefore, the current account on file will be billed and we will not be responsible for return charges from National Fitness Center’s processing bank and/or your bank as a result of the delayed notice. BEFORE SUBMITTING: Please review the information above for accuracy. National Fitness is not liable for any fees that you incur due to the reporting of inaccurate information.