Feb 2017 8 Week Challenge - Member's Payment

Thanks for joining in the Mick’s Gym 8 week challenge. Please complete the payment form below and select your preferred payment method.

Name*
First Last
Email Address*
Phone Number*
Please choose your payment method for $59
Payment Option*
- Pay using Visa/MasterCard/Amex
- Direct debit from my bank account
8 Week Challenge
Price:
Credit Card

American Express
MasterCard
Visa
Supported Credit Cards: American Express, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Direct debit from my bank account
We will direct debit the $59 along with your next scheduled gym membership payment.

Alternatively you can choose a date from the calendar below for us to process the direct debit.

Please ensure you have available funds on this day as failed payments incur an additional $8.80 fee.
DD slash MM slash YYYY

Please choose your payment method for $59