Membership Adjustment Cancellation
RequiredRequired Question(s)
Required 1.
Please enter the information indicated below.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:

Required 2.

What is your preferred method of contact?

Phone
Email
No Preference
Required 3.
How long have you used our facilities, products and equipment?
Less than 6 months
6 months to less than 1 year
1 year to less than 3 years
3 years to less than 5 years
5 years or more
Required 4.
How do we rate on the following attributes?
 Well Below Average Below Average Average Above Average Well Above Average 
Customer service
Professionalism
Quality of equipment
Understanding customers' needs
Sales staff
Price
  • Comment:

  • 500 characters left.
Required 5.

We understand that you wish to cancel your membership?

Yes, Cancel my membership
No, please contact me
Required 6.

I understand I will be billed for 1 more month if the date and time stamp on this request is not completed and received by midnight on the 20th of the month. 

Yes I understand
No, I do not understand
  • Comment:

  • 500 characters left.