cancellation / transfer

I, ________________________________________ , would like to give a minimum 14 days End Date:

notice or equivalent to 1 final payment as per my contract to cancel / transfer my gym
membership as of today.

please cancel my direct debit account

Reference Number: Date of Birth:

I am cancelling within my minimum
term contract and I am aware that I
am required to pay the remaining
payments of the minimum term.
I have fulfilled my minimum term and
would like to terminate my contract
at X2166 Training Centre. I am aware
that a total amount of $ ________ will
be debited from my account on
____ / ____ / _____
I am cancelling within the Cooling Off
Period as per my membership
contract and I am aware that I am
required to pay $40.00.

Reason for Cancellation:

please transfer my remaining term to

First Name: Last Name:

Date of Birth: Remaining Term:

Transfer fee of $40.00 paid by:

Cash Eftpos Credit Card Cheque Charge to account

thank you for being a valued member of X2166 training centre!

Do you have any suggestions on where you think we may need improving?

Signature: ________________________________________ Date: _____ / _____ / ______

Staff: ________________________________________

L 2 & 3, 239 Canley Vale Rd, Canley Heights NSW 2166

P: (02) 9755 9993 W: x2166.com.au E: reception@x2166.com.au ABN: 79 633 051 117