GPACT Membership Cancellation Request Form

GPACT Membership Cancellation Request
Date

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Email
example@example.com
What is the main reason for cancelling your membership?

MedicalFinancialNon-UsageRelocationMotivationOther
On a scale of 1-5 (5 being the highest), how do you rank your overall experience with GPACT?
What were your desired goals when you joined GPACT?
Did you/we meet those goals?

YesNo
Would you like to share anything about your experience with GPACT?

We want your input!

	Definitely	Probably	Not Sure	Probably Not	Definitely Not
Will you use our service in the future?
Will you recommend our service to others?

How can we improve our service?
I hearby certify that I wish to cancel my membership with The Global Professional Association for Colon Therapy. I understand that my account must be in good standing in order to complete this requst. I understand that I am responsible for any billing that will occur within the next 30 days. I understand I will be provided a copy of the Member Cancellation request via email.
Name

First NameLast Name
Signature

Clear
Internal Use Only
Cancel Date:

MonthDayYear
Date
Payment Balance (30 Days After Cancel Date)
Membership End Date

MonthDayYear
Date
Last Usage Date
Consultation Offered

YesNo
Options Offered
Additional Notes
Should be Empty:

GPACT Membership Cancellation Request