Membership Action Form

Membership Action Form
Membership Tag Number:
I,your name*, hereby authorise the following changes to be made to my membership and, if applicable, my existing contract with DebitSuccess, and I understand that changes to my direct debit payments will only be implemented prior to the next debit date if received at least 3 working days prior to that date.
Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature:
Suspension Request
View suspension terms and conditions
Suspension Period
Suspension start date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Planned date of return to LLC:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Reason:

Other
Payment:
If required, please click the button below to upload your medical certificate:

Browse Files

Cancelof
Update bank details for Direct Debit
Financial Institution Name:
Account Name (name of account holder):
BSB:
Account number:
Updated credit card details for Direct Debit
For cyber safety reasons, credit card details cannot be submitted via an online form.

To update your direct debit credit card details, please submit your require in-person at Centre reception or email llc.admin@harvey.wa.gov.au
Request a Change to Your Membership

eg. upgrade/downgrade inclusions or change type of membership
Current Membership:
Change to:
UPGRADES

For Direct Debit Memberships, you will be notified of the new fortnightly instalment amount once processed. For Upfront Memberships, you will be notified of the upgrade price once processed, to be paid at reception. Members are also required to complete a Variation Form for Direct Debit upgrades. Please contact a our Memberships Officer for more information.

DOWNGRADES

No monetary refund will be given and Direct Debit instalment amounts will not be reduced. Instead, bonus days equivalent to the difference in value will be added to the remaining time of the membership.

Please allow up to 14 business days for processing.
Change of personal details
Previous name:

First NameLast Name
Current name:

First NameLast Name
New email:
example@example.com
New address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New phone (home):
New phone (mobile):
Should be Empty:

Membership Action Form

Suspension Request

Update bank details for Direct Debit

Updated credit card details for Direct Debit

Request a Change to Your Membership

UPGRADES

DOWNGRADES

Change of personal details