DEACTIVATE MEMBERSHIP FORM
HRA#
BDR
*
Date request submitted
/
Month
/
Day
Year
Date
Corporation Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Activation?
*
Member was made Inactive in error
No record on why member was deactivated
Member left temporarily
See Comment
Comments
Reason for Deactivation?
*
Sold Store/New Owner
Store Closed
Wants to leave HRA
Member of another TA
See Comments or Attached File
Comments
Attachment
Browse Files
Cancel
of
Date request received
/
Month
/
Day
Year
Date
Has the request been approved?
Yes
No
Comments
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Submit
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