Group Fitness Director Autoship Authorization Form

INSTRUCTOR INFORMATION

How many instructors would you like to approve to be added to your facilities autoship payment information:
If you have more than 10 to approve, please fill out an additional form. *

If you need to remove instructors from your Autoship, please request a report from kelcyrourke@mossa.net.

Please note, this form is not indended for use to register instructors for upcoming trainings. Please use the Training Registration Form to register your instructors.

	Instructor #1
first name	Instructor #1
last name	Instructor #1
branch	Instructor #1
program(s) to add	Instructor #1

	Instructor #2
first name	Instructor #2
last name	Instructor #2
branch	Instructor #2
program(s) to add	Instructor #2

	Instructor #3
first name	Instructor #3
last name	Instructor #3
branch	Instructor #3
program(s) to add	Instructor #3

	Instructor #4
first name	Instructor #4
last name	Instructor #4
branch	Instructor #4
program(s) to add	Instructor #4

	Instructor #5
first name	Instructor #5
last name	Instructor #5
branch	Instructor #5
program(s) to add	Instructor #5

	Instructor #6
first name	Instructor #6
last name	Instructor #6
branch	Instructor #6
program(s) to add	Instructor #6

	Instructor #7
first name	Instructor #7
last name	Instructor #7
branch	Instructor #7
program(s) to add	Instructor #7

	Instructor #8
first name	Instructor #8
last name	Instructor #8
branch	Instructor #8
program(s) to add	Instructor #8

	Instructor #9
first name	Instructor #9
last name	Instructor #9
branch	Instructor #9
program(s) to add	Instructor #9

	Instructor #10
first name	Instructor #10
last name	Instructor #10
branch	Instructor #10
program(s) to add	Instructor #10

CONTACT INFORMATION & PAYMENT:

Please fill in the following information of the person filling out this form.

By filling in the information below you accept that you are authorized by the facility to make legal decisions on their behalf.

first name *

last name *

facility name *

position *

address line1 *

address line2

city *

state *

zip code *

email *

phone number *

Billing Information

Please enter your credit card information below to be billed on your credit card. The Accounting Contact listed below will receive receipts/invoices.

Accounting Contact *

Accounting Contact Email Address *

Name on Card

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CSV 3-digit code *

Billing Street Address for Credit Card *

Billing City for CC *

Billing State for CC *

Billing Zip Code for CC *

Additional Comments

Please note, this form is to authorize Autoship charges for the next Autoship billing. To order the current release for your instructors, please order from the MOSSA Store.