MEMEBERSHIP SUSPENSION REQUEST FORM

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  MEMEBERSHIP  SUSPENSION  REQUEST  FORM      

Mantra  Suspension  Policy:   I  understand  I  may  suspend  my  membership  up  to  twice  per  year  for  a  minimum  of  2  weeks  and  a  maximum  of  1  month.     Suspensions  are  only  accepted  via  this  form  and  a  $15  fee  will  be  charged  at  the  time  of  processing.       Your  account  will  automatically  reactivate  on  ___________.  Indicate  date  below  and  your  auto/pay  will  resume.      

SECTION   1:  TO  BE  COMPLETED  BY  MEMBER      

                           Today’s  Date:  __________________________________________________________                                Client  Name:  __________________________________________________________                              Phone:  ___________________________________________________________________                                Suspension  dates:       Start  Date:____________________  End  Date:  ___________________                                            Reason  for  suspension:  _______________________________________________________________________________________________________________________                       SECTION  2:  SIGNATURES      

I,  ____________________________________________,  acknowledge  the  suspension  procedures  and  my  membership  will  go  back  into  activation   once  the  requested  suspension  time  period  has  expired.    

Member  Signature:  _______________________________________________________________  Date:  ______________________________________________________________________________   Name  of  person  who  accepted  the  cancelation  form:  ____________________________________________________________________  Date:  ____________________________________   Date  Cancelled:  __________________________________     RECEIVING  STAFF  SIGNATURE____________________________________________