DVD Rental Membership Cancellation Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Membership/Account Number

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Reason for Cancelling Membership

Please provide additional details (optional)

Do you currently have any DVDs that need to be returned?

Have you cleared all outstanding payments and fees?

How satisfied were you with the DVD rental service?

Please share any feedback or suggestions for improving our service (optional)

Signature (Please sign to confirm your cancellation request)