Grocery Delivery Membership Cancellation Form
Please complete this form to cancel your grocery delivery membership. All fields are required to process your request.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Membership ID or Reference Number (if available)
Preferred Cancellation Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Cancellation
*
Please Select
No longer need the service
Dissatisfied with service
Found a better alternative
Moving out of service area
Cost concerns
Other
Additional Comments (optional)
Acknowledgment of Cancellation Terms: I understand that my membership and related benefits will end as of the selected cancellation date, and any scheduled deliveries after this date will be canceled.
*
I acknowledge and agree
Submit Cancellation
Should be Empty: