Online Loyalty Rewards Enrollment Form

Membership

Date*

Date

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Membership Certification*

Everything that I/We have stated in this form is to the best of my/our knowledge. I understand that this form will be retained by Packatac Power Sports, LLC. for records purposes only. This form will not be disseminated or released to any third parties or other businesses. I authorize you to notify me of new information, partnerships, or changes to the Loyalty Rewards Program. These notifications may be done through mail and/or e-mail. I understand that I may cancel this membership at any time by writing to Track Side or Headwaters Polaris, at least 15 days prior to the next annual billing date. I understand that a $50.00 processing fee will apply, if I cancel my membership within 15 days of joining.

Recurring Payment Authorization*

Schedule your annual Loyalty Rewards Program fee automatically from your credit card by completing and signing this form. By authorizing the annual scheduled charges to your credit card, you will automatically be charged $199.00 for our Loyalty Rewards Program membership fee, plus applicable taxes. A receipt for the annual payment will be provided to you upon request and the charge will appear on your bank statement. The payment will come initially for joining and then on the last month of your annual membership period for the following year, as indicated below. A $50.00 processing fee will be applied to credit card if you cancel your membership within 15 days of the date indicated below.

I, First Name* Last Name* authorize Packatac Power Sports, LLC. d/b/a Track Side or Headwaters Polaris to charge my credit card indicated on this form below for $199.00, plus taxes/fees annually from the date indicated on this form above.

My Subscriptions

Online Annual Loyalty Rewards MembershipTrack Side and Headwaters Polaris Loyalty Rewards Annual Membership

$199.00 for each year

Enter coupon

Subtotal

$0.00

Tax

$0.00

Credit Card

Authorization to Enroll*

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify Track Side or Headwaters Polaris in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next annual renewal date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond with the terms indicated in this authorization form.

Signature