Name: ______________________________________

Address: _____________________________________________________

City: _____________________   ZIP: ________________

Daytime Phone: _________________________   Evening Phone: ____________________________

Date of Birth: _______________   Email: _______________________________________________

HBA Monthly Membership Registration Form

Amount: $________________

Credit Card Number: __________________________________   Exp Date: ___________________

Name on card: _______________________________________   CVV (code on back): _____________

Billing Address: __________________________________________   ZIP: _____________

Monthly COST: (You will be  AUTOMATICALLY charged each month

via your credit/debit card on file)                                                      $10.00 per month**

Sign-up Fee: (Waived for first membership month)                 $  9.95***

**You must give a 60 day notice to cancel your membership and be a member for a  minimum of 3 months.  Your Member fee is guaranteed for 12 months.

***This fee is waived the first month of being in the program.  If you start then stop and then restart your membership the sign-up fee will apply.

I agree to the terms of the monthly membership fees:

________________________________________________________________     ______________

Print Name   SignatureDated

 

Cancellation Policy:

NO REFUNDS FOR ANY REASON.

FAX  this Form to:  (408) 866-8088