MEMBERSHIP CANCELLATION FORM

COMPLETE THE FORM BELOW TO CANCEL YOUR MEMBERSHIP.

PERSONAL DETAILS
First Name Sandra Mobile 0 4 0 4 7 7 7 1 2 0
Last Name Wipiiti Email Wipiiti@gmail.com
1 9 7 3
DOB 1 2 Membership # Don't know
0 9
Reason for cancellation:
Breach of Club rules Work commitments Not using Club Non-payment of fees

Can’t afford fees Dissatisfied with Club Moving away Medical reason

Other

ACKNOWLEDGEMENT

This membership cancellation will be effective from: A s a p

I acknowledge that by signing this form I will be stopping my Jetts membership access and direct debits. Where my
notice is received by 5pm on a business day it will be processed with same day effect. Notice received after 5pm will be
actioned the next business day. Any outstanding payments must be made prior to this cancellation taking effect. Where
payments are up to date I shall have the right to use the club for the remainder of my pre-paid period.

Member’s signature:
Date: 0 6 / 1 0 / 2 0 1 9

ADMINISTRATION ONLY
Membership Details:
No last month DD paid Last month DD paid PIA membership Refund Due PIA membership Transfer

Date Received: Cancellation Processed:

Team member’s name:

© Confidential All Rights Reserved : F122V3.04022014 Page | 1 of 1