Client Cancellation Request Form

Client Cancellation Request
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
What is the Main Reason for Your Cancellation Request?
What did you like and dislike during your experience with STBD?
What were your goals when you started with us?
Did we meet those goals?
If you could choose your price for the services you signed up for, what would you pay for those services?
Which services did we perform for you?

Other
How would you rate our staff?
Did you find our staff knowledgeable?

We value your feeback

Rows	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?
We failed getting you excited about your business goals. Are you open to giving us another chance, with no obligation to stay. Please rest assured, that your cancellation request will still be processed, as per your request.

Other
I hereby certify that I wish to cancel my contractual agreement with Simply The Best Digital. I understand that my account must be in good standing in order to complete this request. 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 Cancellation Request via email. Lastly, I understand that the cancellation request may not be approved.
Name

First NameLast Name
Signature
Internal Use Only
Cancel Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Payment Balance (30 Days After Cancel Date)
Effective End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last Usage Date
Consultation Offered
Options Offered
Active OS Agreement
Additional Notes
Person Handling This Request:

First NameLast Name
Should be Empty:

Client Cancellation Request