Recurring ACH Payment Authorization

By signing below, you authorize Billings Jiu Jitsu, LLC to charge your bank account indicated below for the agreed upon monthly tuition on the 3rd day of each month. A receipt for each payment will be provided to you and the charge will appear on your bank statement as “ACH Debit”. You agree that no prior notification will be provided unless the date or amount changes, in which you will receive notice from us at least 10 days prior to the payment being collected. This payment is for martial arts instruction.

Billing Address

Billing Address Line 2

City

Region/State/Province

Postal / Zip code

Account Number

Routing Number

Your Signature

Student First Name

Student Last Name

Account Holder First Name

Account Holder Last Name

Account Holder Phone

Account Holder Email

Account Type:

Checking

Savings

Credit Card

Membership Type:

Adult ($110/mo)

Child ($65/m0)

Punch Card ($150 one-time)

Credit Card

Exp. Date

Security Code

Thanks for submitting!

Roll on the mat or around town in style. GET YOUR BILLINGS BJJ GEAR!

Recurring ACH Payment Authorization