Membership Cancellation Closure Checklist Form
Membership Cancellation Closure Checklist Form
Member Full Name
*
First Name
Last Name
Membership ID or Reference Number
*
Cancellation Request Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Cancellation
Please Select
Dissatisfied with service
No longer needed
Found alternative provider
Financial reasons
Other
Checklist: Select all steps completed
*
Account status updated to cancelled
Final communication sent to member
All access and benefits revoked
Outstanding balances checked/cleared
Assets, cards, or equipment returned (if applicable)
Additional Notes (optional)
Closure Completed By (Staff Name)
*
Closure Completion Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Checklist
Should be Empty: