VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526 Richmond, VA 23218-0526
(804) 786-1343, Option 4 www.vdacs.virginia.gov ocrpregulatory@vdacs.virginia.gov
OCRP-32 Revised 04/2020
REMITTANCE FORM
HEALTH CLUB
Annual Registration Fee (930-02188)
Late Fees* (930-02180)
Total Fees Submitted
Check Number
Make check payable to the Treasurer of Virginia
Health Club Facility Name and Address:
ANNUAL REGISTRATION FEE SCHEDULE
NUMBER OF UNEXPIRED CONTRACTS**
0 to 250
251 to 500
501 to 2000
2001 or more
REGISTRATION FEE
$200
$300
$700
$800
**The number of applicable unexpired contracts shall be separately calculated for each health club location.
PLEASE NOTE: All health club registrations must include the completed registration application, a copy of the current
membership contract and copy of the current membership price list that includes all initiation fees charged, even if
there have been no changes since the last renewal submission.
*LATE FILING FEES
Late Fees for Initial Filing: Health clubs must be registered with OCRP prior to selling contracts. Clubs shall pay a late
filing fee of $100 for each 30-day period the initial registration filing is late. The fees shall be in addition to all other
penalties allowed by law.
Renewal registration applications are due on or before July 1st of each year. Registration applications that are not
POSTMARKED on or before July 1st shall include a late registration fee in addition to the annual registration fee. See
Page 2 of this form for late fee calculations.
Application for Registration Revised 04/2020
Health Club Facility Info
LATE FEE CALCULATIONS
REGISTRATION SUBMITTED (POSTMARKED) LATE FEE DUE (IN ADDITION TO REGISTRATION FEE)
JULY 2
ND
JULY 31 $50
AUGUST 1
ST
AUGUST 31
ST
$75
SEPTEMBER 1
ST
SEPTEMBER 30
TH
$100
OCTOBER 1
ST
OCTOBER 31
ST
$125
NOVEMBER 1
ST
NOVEMBER 30
TH
$150
DECEMBER 1
ST
DECEMBER 31
ST
$175
JANUARY 1
ST
JANUARY 31
ST
$200
FEBRUARY 1
ST
FEBRUARY 28
TH
$225
MARCH 1
ST
MARCH 31
ST
$250
APRIL 1
ST
APRIL 30
TH
$275
MAY 1
ST
MAY 31
ST
$300
JUNE 1
ST
JUNE 30
TH
$325
Application for Registration Revised 04/2020
Health Club Facility Info
VIRGINIA PRIVACY ACT DISCLOSURE
All information disclosed may be used for law enforcement purposes, including civil enforcement of the Virginia
Consumer Protection Act of 1977 and the Virginia Health Club Act. Pursuant to the Virginia Freedom of Information Act,
all information disclosed will be available for inspection by the public.
IMPORTANT
Effective July 1, 2020, pursuant to §59.1-296.2:2 of the VHCA, ALL health clubs must have a working
automated external defibrillator. Per the definition, an automated external defibrillator means a
device that combines a heart monitor and defibrillator and (i) has been approved by the US Food and
Drug Administration; (ii) is capable of recognizing the presence or absence of ventricular fibrillation or
rapid ventricular tachycardia; (iii) is capable of determining, without intervention by an operator,
whether defibrillation should be performed; and (iv) automatically charges and requests delivery of an
electrical impulse to an individual’s heart upon determining that defibrillation should be performed.
Use the following link: https://www.fda.gov/medical-devices/cardiovascular-devices/automated-external-
defibrillators-aeds#approved to verify your AED is FDA approved.
Your bond or letter of credit must be maintained at the level required in the surety schedule contained within
the Act. Failure to maintain the proper surety level will result in late fees as provided by §59.1-296.1, Code of
Virginia, as amended.
You must amend this registration within 21 days if there is a change to the information contained in this
registration statement.
All changes in ownership must be reported to this office 10 days prior to the effective date of change.
If 50% or more of the ownership changes, the facility must register as a new facility at the time of the change in
ownership. Failure to re-register as a new facility will result in late fees of $100 for each thirty-day period or any
part thereof following the date ownership changed.
If no surety is required, your contracts must contain the following disclosure required by §59.1-296.2:1(F): “THIS
CLUB IS NOT PERMITTED, PURSUANT TO THE VIRGINIA HEALTH CLUB ACT, TO ACCEPT ANY INITIATION FEE IN
EXCESS OF $125 OR ANY PAYMENT FOR MORE THAN THE PRORATED MONTHLY FEE FOR THE MONTH WHEN
THE CONTACT IS INITIALLY EXECUTED PLUS ONE FULL MONTH IN ADVANCE.” Please refer to page 2 of the
registration form for surety requirements.
This office will strive to have your registration application and required documents reviewed within 30 days of
the receipt of the registration submission. Before contacting us, please allow sufficient time for review and
processing. During higher activity periods, processing time may be longer.
If you have any questions or need additional information, please contact us at
ocrpregulatory@vdacs.virginia.gov or at 804-786-1343, Option 4.
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526 Richmond, VA 23218-0526
(804) 786-1343 Option 4www.vdacs.virginia.gov ocrpregulatory@vdacs.virginia.gov
OCRP-32 Revised 04/2020
APPLICATION FOR REGISTRATION
HEALTH CLUB
NOTE: Each facility location is required to file a separate registration application.
1. Facility Information:
Facility Name:
Physical Address:
City: VA Zip:
Phone: Contact Email:
Mailing Address (if different from physical address):
City: State: ______ Zip:
2. Ownership Information:
Legal Entity Name:
Mailing Address:
City: State: Zip:
Phone:
3. Business Type (Check One): Corporation Limited Partnership
Sole Proprietorship LLC
4. You must provide the following information for each owner of this health club. If the owner is a Corporation,
Partnership, Limited Liability Company or other entity, the following information must be provided for each owner of
that entity (attach additional sheets if needed):
% of
Name (Last, First, Middle Initial) Address (street, city, state, zip) Interest
5. Did any of the owners listed in question 4 previously own, in whole or in part, a health club facility that closed
for business and failed to directly issue refunds or provide comparable alternative facilities to its members?
Yes No
Page 2
Application for Registration Revised 04/2020
Health Club Facility
6. Date when CURRENT owner sold first contract for this location:
MM/ DD/ YYYY
7. Date this location first opened for full and regular use by members. If not opened yet, the date this location will
open for full use by members (Current Owner):
MM/DD/YY
8. State the total number of active/unexpired contracts (from Question #1 Schedule A):
9. State the total number of active/unexpired bondable health club contracts (from Questions #9
Schedule A):
You must submit the ORIGINAL surety (irrevocable letter of credit, surety bond or cash) in the amount appropriate for
the number of contracts stated in question 9 (see schedule for amount of surety required below). There is no need to
submit copies of bonds or letters of credit that are currently on file with the Commissioner.
AMOUNT OF SURETY REQUIRED
NUMBER OF BONDABLE CONTRACTS
0 to 250
251 to 500
501 to 750
751 to 1,000
1,001 to 1,250
1,251 to 1,500
1,501 to 1,750
1,751 to 2,000
2001 or more
SURETY AMOUNT
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$100,000
10. Has this health club filed surety with the Commissioner? Yes No
11. For each health club with a bond or letter of credit, specify:
a) Bank/Insurance Company Name:
b) Serial # or other identification # of the bond or letter of credit:
c) Amount of the bond or letter of credit:
d) Date issued/effective:
Page 3
Application for Registration Revised 04/2020
Health Club Facility
12. All health clubs are required to have a working automated external defibrillator (AED). Please indicate the
Manufacturer and Device Name of the one(s) located in this club (attach additional sheet if needed):
A. Manufacturer: Device Name:
B. Manufacturer: Device Name:
C. Manufacturer: Device Name:
D. Manufacturer: Device Name:
13. Please indicate the general location(s) in your club where the AED(s) listed above is/are located:
A.
B.
C.
D.
I CERTIFY THAT ALL THE INFORMATION CONTAINED IN THIS REGISTRATION APPLICATION IS
TRUE AND CORRECT:
Date: Signature:
Title: Print Name:
Page 4 Revised 04/2020
Schedule A - Calculation of Bondable Contracts
TOTAL CONTRACTS
1
What is the total number of unexpired/active
contracts? (Total number of contracts, regardless of
type/term of contract, i.e.: month-to-month, 12 month,
etc.)
MULTIPLES CALCULATIONS
2
What is the total number of unexpired/active contracts
with a term that exceeds 13 months?
3
What is the number of unexpired/active contracts
from Question 2 that are payable only on a monthly
basis and the initiation fee collected is no more than
$250?
4
Subtract the number in Question 3 from the number in
Question 2.
5
Divide the number in Question 4 by the number in
Question 1. (This determines percentage of contracts
that are multiples).
BONDABLE CALCULATIONS
TOTAL BONDABLE
CONTRACTS
6
What is the total number of unexpired/active contracts
with an initial term 13 months or less, where you
collected more than a $125 initiation fee and/or more
than one month, and a prorated monthly fee for the
month when the contract was initially executed, in
advance?
Enter the number of
contracts into the box
7
What is the total number of unexpired/active contracts
with an initial term 24 months or less, but more than
13 months, where you collected more than a $125
initiation fee and/or more than one month, and a
prorated monthly fee for the month when the contract
was initially executed in advance?
If percentage in Question 5
is greater than 10%,
multiply the number by 2
and enter the number in
the box. If less than 10%,
enter the actual number.
8
What is the total number of unexpired/active contracts
with an initial term 36 months or less, but more than
24 months, where you collected more than a $125
initiation fee and/or more than one month, and a
prorated monthly fee for the month when the contract
was initially executed in advance?
If percentage in Question 5
is greater than 10%,
multiply the number by 3
and enter the number in
the box. If less than 10%,
enter the actual number.
9
Total number of bondable contracts (add questions 6,
7, and 8). This number determines the amount of surety
required to be on file with the Office of Charitable and
Regulatory Programs, pursuant to §59.1-306 of the Virginia
Health Club Act.
Enter total number of
bondable contracts