Fitness Statement Request

Fitness Reimbursement Statement Request

Do you need a copy of your membership payment statement and/or visit counts for employer reimbursement? Fill out the form below.

Please allow up to 10 business days to receive your statement via email.

First Name*

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Last Name*

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Address

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Apt., Suite, etc.

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City

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State

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Zip Code

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Date of Birth*

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Cell Phone

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Home Phone

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Email (this is where the statement will be sent)*

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Beginning Payment Month/Year of the statement request*

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Ending Payment Month/Year of the statement request*

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Beginning Visit Month/Year of the visit report request

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Ending Visit Month/Year of the visit report request

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Other comments

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