*Name:

*Email:

*Phone Number:

*Reason for Cancelation:

*I acknowledge this request is being submitted two (2) weeks prior to my upcoming scheduled billing. Please initial to acknowledge.

*If the minimum club purchase amount (3 shipments/pickups) has not been fulfilled, you will be charged a $50 cancelation fee as well as the amount of any discounts received.Please Initial to acknowledge:

*Would you like to have any pending orders shipped to your address on file? *If yes, Standard shipping will be charged to the credit card on file. Yes No

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