Module Termination Request Form
Submit your request to terminate or deactivate a specific module. Please complete all required information to ensure prompt processing.
Full Name of Requester
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Organization
Module Name to be Terminated
*
Module Type
*
Please Select
Software Module
Course Module
Subscription Service
Hardware Module
Other
Associated Account or Reference Number (if applicable)
Reason for Module Termination
*
Please Select
No longer needed
Switching to another module/service
Cost-related reasons
Technical issues
Dissatisfaction with module
Other
Requested Termination Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please provide any additional comments or specific instructions regarding the termination (optional)
How did you access this module?
Direct purchase
Through organization/department
Trial version
Other
Do you have any outstanding issues or support tickets related to this module?
Yes
No
Submit Request
Should be Empty: