Pre-Authorized Payment Authorization - US Customers Only

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Account Information
Equinox Account Number	*
Email Address	*
Name	*
Address	*
City	*
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Telephone	*
Bank Information
I(We) authorize Equniox Credit Services Inc. to process a debit, in paper, electronic or other form in the amount I will specify from time to time to be drawn on the following bank. * I(We) ("Equinox Account Holder") acknowledge that this Authorization is provided for the benefit of Equinox Credit Services Inc.
Bank Name	*
Bank Address	*
City	*
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -- Select -- *
Zip/Postal Code	*
Country	USA
Account Information
Bank Routing/ABA Number	*
Bank Account Number	*
Bank Account Type	Checking Savings
Terms and Conditions
Please read our Terms and Conditions before continuing If you would like to print a copy of this documents click on the links below Terms and Conditions I(We) warrant and guarantee that all persons whose signatures are required to sign on this account have read and accept the terms of this Agreement. *