Cancellation Request Form
To: Darul Uloom Michigan
2446 E 12 Mile Rd
Warren, MI 48092
Dear Muhtamim,
I am withdrawing my child(ren) from the Darul Uloom Michigan program. I kindly
request that you cancel the monthly fee direct deposit for my child(ren), effective
from the next billing cycle.
I understand that if I choose to re-enroll my child(ren) in the future, I will be required
to reapply as new students.
Student(s) Name
*
Account Holder Name
*
Account Number
*
Home Address
*
Phone Number
*
Format: (000) 000-0000.
Monthly fee amount
*
Reason for leaving:
*
Signature
*
Parent/Account Holder
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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