Page 1

World Wellness Education Membership Agreement

Chapter

Name

Date

Address

City

Email

State

Home Phone

Zip Code

Cell Ph

Employer

Occupation

How did you hear about us?

As a member of World Wellness Education, I agree to attend as many meetings as I can and to participate to my ability in the community outreach programs. I understand that the goal of this membership is to educate myself and others in living a life of wellness. I know that a big part of reaching this goal requires me to volunteer on a committee that will serve the overall mission of the club. Membership is for one year and dues are to be paid quarterly or in full. Quarterly payments will be automatically deducted from a checking account or credit card of my choosing. Meetings can be attended at any chapter of World Wellness Education. Signature _____________

______________

Dues are $100.00 Pay in Full:

Pay Quarterly:

Authorized Agreement must be completed if payment

is to be paid quarterly.

AUTHORIZED AGREEMENT FOR PREAUTHORIZED PAYMENTS FOR DUES I (We) hereby authorize the Wellness Educational, Org. hereinafter called COMPANY, to initiate debit entries, and corrections thereto my (our) checking, savings or charge card account indicated below and the depository credit card named below, hereinafter called DEPOSITORY. Name_______________________ Expiration Date____________

Credit Card/Debit Card Number ___________

_________________

CVV ____________

Annual Payment ($100.00) _____ or Quarterly Pmt($25.00 per quarter) ____ * Dues may be pro-rated depending on the date of membership. This authority is to remain in full force and effect until COMPANY and DEPOSITORY have received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY AND DEPOSITORY a reasonable opportunity to act on it, or until all payments due under the contract have been made. Signature_______________

____________ Date____________

TO BE COMPLETED BY CHAPTER TREASURER ONLY: Paid in Full: Date: st

Paid Quarterly: 1 Qtr Paid: 3rd Qtr Paid:

Date:

2nd Qtr Paid:

Date:

Date:

4th Qtr Paid:

Date:

Give to local club president or fax to (352) 365-6376 Addendum T


Membership Agreement  

Complete this in full and turn in to become a member

Advertisement
Read more
Read more
Similar to
Popular now
Just for you