Cooley Membership Cancellation request

Cooley Membership Cancellation request
Name*

First NameLast Name
Email*
example@example.com
Social Security Number or Employee Payroll Number (EID#)*
Member Number
Hopkins Status
Membership Status*
if '2 member' or 'family', what are the family members names?
Reason for cancellation*
If 'other', please explain
Cancellations are only granted after the initial six-month contract has been fulfilled Early cancellations will be considered only if: Employment is terminated from Johns Hopkins or affiliate Medical Reasons – This must be accompanied by a doctor’s note on official letterhead Membership deductions should cease within 30 days of the Cooley Center receiving cancellation form
Signature:*

Clear
Date:*

MonthDayYear
Date
Membership deductions should cease within 30 days or less of the Cooley Center receiving cancellation form

Denton A. Cooley Center – 1620 McElderry St., Baltimore, MD 21205 – 410-955-2513
Should be Empty: