AF Membership Freeze
Staff Name
*
Josh Moore
Corey Bryanton
Emma Clarke
Jake Taylor
Hayley Bourque
Jessica Moore
Member Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Membership Dues
*
Membership Dues Frequency
*
Biweekly
Monthly
Freeze start date (must align with billing date):
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of payments frozen:
*
I understand that my membership will be extended by the above number of payments at the conclusion of the original end date. ABC Financial will not bill my account until the below date at which time I will continue to be billed at my regular rate (stated above) and frequency.
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I understand that the April 1st & October 1st Club Enhancement Program is not frozen in conjunction with regular membership dues. If my freeze overlaps these dates, I understand these payments will still process.
*
Yes
Reason for Freeze
*
Medical
Financial Hardship
Travel
Military Deployment
Time/Usage
Member Signature
Submit
Should be Empty: