Mosman Swim Centre -

DEPARTURE REQUEST FORM

The below departure request form is applicable for Mosman Swim Centre Memberships only. Please note if you are an Ezyswim member, please visit www.ezyswim.com.au to complete applicable departure request form.


	Surname:*


	First Name*:

	Member Number (if known):


	E-Mail*:


	Address:


	Contact Numbers:

	Home Phone:

	Work Phone:

	Mobile Phone:


	Membership Type:

	Membership Type*:

Reason for Departure:

		Taking a Break

		Medical Reason
		Dissatisfied
		Financially unable to continue
		Relocating
		Personal Reasons
		Lacking Motivation / Too busy


	Feedback: We appreciate you taking the time to give us some feedback.

	What areas did you enjoy?



	What areas need improvement?



	Would you recommend us to others?



	Would you like us to contact you?

Please terminate my membership. I understand and agree that a membership may be cancelled for the following calendar month by giving notice by the 15th day of the current month. I acknowledge the fact once I do so, Mosman Swim Centre cannot guarantee the same membership will be available when joining in the future.

Example: depart before the 15th March to end membership on 31st March and not be charged for April.

Please note: Departure requests received after the 15th day of the current month will not take effect until the month after. Please clearly read the example below:

Example: depart on the 16th March or later you will still be charged for and able to swim until the end of April. Your departure will be finalised on 30th April and you will not be charged for May.

I agree to the above and am aware that by submitting this form I will be cancelling my membership.


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