VIP  MEMBERSHIP

$22 Monthly Unlimited  Auto Debit

Freeze it for 2 months a year—Cancel at any time after 3 months

Level 1 Beds

Name First_______________________________________Last____________________________________

Billing Address_____________________________________city__________________zip_______________

  Phone #____________________________________________________________

 Circle One:     Visa      Mastercard         Disc          Amex         Checking      Savings

 Account #___________________________________________

 Bank Routing #________________________________________

  9 digit # bottom left of check   

 Expires______________________

 Credit card only                      

 I authorize L.A.RAYS to debit my account in the amount of $22 on the 5th of every month

 Any changes or cancellation to my account must be made at the store by the 17th of the previous month

 Cancel at any time after 3 months

 Any account past due will be canceled

 Signature_________________________________Date__________