Perpetual Membership Cancellation Form

First Name

Last Name

Email Address

8-Digit University ID Number

Phone Number

Check the box for each item you are requesting for Perpetual Payroll Deduct Cancellation:

Faculty/Staff Membership (Selecting this option will cancel all memberships/lockers on your account)

Sponsored Spouse/Domestic Partner Membership

Sponsored Dependent 4–18 Membership

Locker Rental

Specify Sponsored Member(s) you wish to cancel.

Requested Date of Cancellation. Note: Your membership will remain active through the end of the month selected with the final deduction appearing on the paycheck following the selected month (example - if you select October 1, the membership will remain active through October 31st. Your final deduction would occur on your November 1 paycheck).

Locker Number

(Provide building and locker number of the locker you wish to cancel)

Today's Date

By submitting the following web form, I understand that refund/credits will not be issued for previous deductions. Memberships and/or Locker cancellations for employees in the Perpetual Payroll Deduction Program become effective no earlier than the last day of the month in which the cancellation notice is requested. Because each month’s membership deductions are for the prior month’s service, the final deduction will occur on the next monthly paycheck after the requested date of cancellation. Yes, I understand the statement.