Cancellation

Name *

First Name

Last Name

Phone *

(###)

###

####

Effective Date of Cancellation *

MM

DD

YYYY

I have read the conditions above and agree that I will be charged $125 or 1/3 of the remaining amount of my contract, whichever is greater *

Yes

I understand that I must give 15 day notice before canceling or I will be charged for the next month *

Yes