Credit Card Processing Information


I, , hereby authorize LifeTrek, Inc. of 121 Will Scarlet Lane, Williamsburg, VA 23185-5043 to charge the following credit card account in the amount and according to the billing cycle shown below for monthly coaching services. I understand that his payment agreement will be in full force and effect until services have been completed or are ended by request of the client either verbally or in writing at the address listed above.


Card Type (Check One): Visa  MasterCard  American Express  Discover
Card Number:
Expiration Date:
Name on Card:
Billing Address:
LifeTrek Billing Cycle:
Coach's Name:
Cardholder's Signature:  


Cardholder's Phone:
Cardholder's E-Mail:

Complete this form on-line except for the signature, print it out, sign it manually, and return it to LifeTrek, Inc., 121 Will Scarlet Lane, Williamsburg, VA 23185-5043 by Fax (772-382-3258) or Surface Mail.