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2. First Name*
3. Last Name*
5. Address1*
7. City*
8. State
   -- Select One --ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
9. Zip
11. Phone*
13. Email address*
15. Select 'Yes' to Complete Withdraw Request:*
    -- Select One --Yes - Terminate Auto-Draft

    By selecting 'yes', I request to terminate my auto-draft membership plan. If the written request is received five days prior to your billing date, your credit card will not be charged again and the membership will be terminated. If the cancellation request is submitted after your card has been billed, your account will be active for the next 30 days. Monies paid in advance toward an Auto-Draft Membership are not refundable, including payments processed in advance for renewal for the subsequent 30 days.
17. Reason for canceling auto-draft*

    Please check all that apply

    1. Light use or schedule conflict
    2. Budget
    3. Joined another gym (please specify below)
    4. Moving
    5. Medical
    6. Summer use only
    7. 7 Day Free-Trial
19. Other gym joined or reasons for withdraw/comments
    Please state reason if not listed above or leave a comment
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

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