Please provide the following contact information:

First Name
Last Name
Phone
Store you will Tan at (Arnold or South County)
E-mail

Billing Address
City
Zip

Please provide your account information:

visa , mastercard discover,amex checking or savings #
Routing number	9 digit # on bottom left of check (if you are using this account for debit)
Expiration Date	if using credit card

Date You will start Tanning

• 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

There is a one time Membership Fee of $15

After you submit this form your account will be charged