Change of Ownership

Request for Account Ownership Change
ATTN: Client Services Administrator

I hereby request to relinquish ownership for the website listed below:
Website address/URL:*
Please provide the following information for who will be taking ownership of the account:
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
I understand that by requesting to relinquish ownership, all services and domains tied to the website address listed above will be transferred within 14 days of receiving this form. My billing information will be removed, and it will be the responsibility of the acquiring doctor to update this information.
E-Signature*

Clear
Date*

MonthDayYear
Printed Name:*
Should be Empty:

Request for Account Ownership Change