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ACH Information for Direct Transfer of Membership Dues

* Indicates required field

Name *

First

Last

Email *

I (we) authorize Latitude 44 Yoga Studio to electronically debit my (our) account and, if necessary, to electronically credit my (our) account to correct erroneous debits as follows:

Status *

New Membership Change My Membership Change My Payment Method to ACH

Preferred Start/Change Date *

Membership Selection *

Unlimited ($99/month) Unlimited Annual ($999/year) Does not auto-renew 9x/Month ($74/month) 5x/Month ($50/month) Online LIVE + On-Demand ($54/month) On-Demand ($34/month) Karma Membership

Name of Financial Institution *

Account Type *

Checking Savings

Bank ROUTING Number (must be 9 digits) *

Manually Re-Enter Bank ROUTING Number *

Bank ACCOUNT Number *

Manually Re-Enter Bank ACCOUNT Number *

Do the account numbers listed match? *

Yes No (please re-enter the correct number)

Name(s) on the Account *

Debit Transaction Frequency *

Recurring Debits / Monthly Debits

Authorized Debit Amount *

I authorize Latitude 44 Yoga Studio, LLC to transfer funds from my bank account to cover monthly expenses related to my membership dues as well as make any adjustments for any debit entry errors to my account. If funds are not available in my bank account, I authorize Latitude 44 Yoga Studio to utilize my credit card that is on file to cover these expenses. Latitude 44 Yoga Studio reserves the right to charge $15 per incident for any EFT reclear fee, unpaid EFT draft, declined credit or debit card, unpaid credit card chargeback, or late payment. I (we) understand that this authorization will remain in full force and effect until I (we) notify Latitude 44 Yoga Studio has received written notification via the webform at latitude44yoga.com/cancel that I (we) wish to terminate or change in such time and in such manner as to allow Latitude 44 Yoga Studio 30 days notice to act on it. [Electronic Signature] *

Today's Date *

Submit

313 E. Madison Street
Eau Claire, Wisconsin 54703
Studio: (715) 828-3936
Email: info(at)latitude44yoga.com
Facebook @latitude44yoga
Instagram @latitude44yoga

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