This form can be used for providing payment by credit card or debit card for an existing website, e-mail or phone order.

Order Number

Card Holder Information

First Name

Last Name

Billing Address

State

Suburb

Postcode

Mobile

Payment Authorisation

Card Type

Visa

Mastercard

Card Number

Expiry Date

Card Identification Number

I am hereby authorising the Lifespan Fitness to process a charge through my credit card account in the amount of $

*IMPORTANT: Customers are required to attach a scan or photograph of your credit card (front) and driver's license (front) to verify your signature and identification. We will not be able to process your payment without this.*

*Personal information collected from you is held and used by Global Fitness and Leisure Pty Ltd under the provisions of the Privacy andPersonal information Proection Act 1998

The supply of information is voluntary, however if you cannot provide, or do not wish to provide the information sought, Global Fitness and Leisure Pty Ltd may be unable to process your request.

Please note: Global Fitness and Leisure Pty Ltd will not keep a file of your credit card details. At the completion of the transaction, this form will be discarded and any records will destroyed.

Attach Scan of Credit Card

Attach Scan of Driver's License