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Member Type *
Grand Patron - $5000 Patron - $1000 Life - $50 ($100)
Associate Member (Student only) - $0
   
First Name : *
Last Name : *
M I :
Profession :
Email Id : *
Address 1 : *
Address 2 :
City : *
State : *
Zip : *
Home Phone :
Mobile Phone : *
Fax :
Website Address :
Would you like to register for ATA Discounted LA Fitness Membership *
Marital Status *
Spouse First Name : *
Spouse Last Name : *
Spouse Mobile :
Spouse Email : *

Name of the children ( Age )

Additional Info/Comments :
Referred By : (If no one referred, enter "Self") *
If you enter a coupon code, you must click the apply button
Coupon Code :

Payment Details
Card Type *
Card Holder Name *
Card Number *
Exp. Date * (mm/yyyy)
CVN * CVN
 
  I agree to the terms and conditions.
 
 
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