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Membership Cancellation

VIEWS: 19 PAGES: 1

									                                                                                       Membership Cancellation
                                                                                              Today’s Date: ________________________




Name: ________________________________________________________________ Birth date: ___________________________________

Address: ____________________________________________________________________________________________________________

City:___________________________________________________________________ State: ____________ Zip: ______________________

Phone (W): _______________________________________________ Phone (H):_________________________________________________

Ohio State E-mail: ______________________________________________ Other e-mail:___________________________________________

Reason for cancellation: _________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Would you like to cancel family members?         Yes      No

If yes, names: ____________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Ohio State employee payroll schedule:         Bi-weekly    Monthly

Notes: _________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________



Note:                                                                      Please indicate payment method:
1. A written cancellation notice is required 30 or more days prior to       Credit Card (check one)
   actual cancellation date with the following month serving as the last    VISA     Mastercard       Discover   American Express
   month to be charged.
                                                                            CC # ___________________________________________
2. If family members wish to continue the membership, one family
                                                                            Expiration Date: __________________________________
   member will become the prime member and will be charged
   accordingly                                                              Check Enclosed

3. A $40 processing fee is applied for early cancellation within
   first 12 months of membership.



Member Signature: ____________________________________________________ Date: _____________________________________

Staff: _______________________________________________________________ Date: _____________________________________


Please fax this form to (614) 292-4105, deliver to the RPAC Welcome Center, or e-mail carpenter.376@osu.edu.


For office use only:

Rec Sports Staff: ___________________________________________________ Date:_________________________________________

Actions: ________________________________________________________________________________________________________

Cancellation payment processed:         Yes     No

								
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