Application for Membership Suspension
* Indicates a mandatory field
Full Name*
Membership Number
Email*
Work/ Home Phone*
Mobile Phone
Membership Type:
Health and Fitness
ShapeHer
Membership Payment Type:
Fortnightly Bank Account
Fixed Term / Lump Sum
Fortnightly Credit Card
ECU Staff Payroll
Did you sign up at:
Joondalup
Mount Lawley
Suspension Details
Reason for suspension:
Non-Medical (Cost $10 per month)
Medical (No charge - Medical Certificate required)
ECU Staff Member Work Related
Suspension start from:
<
May 2013
>
Mo
Tu
We
Th
Fr
Sa
Su
29
30
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Length of suspension:
2 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
12 Months
End date:
06/06/2013 Thu
Amount:
$10.00
I will pay the above amount by:
Online Credit Card Payment
Current bank details on record with ECU Sports
ECU Staff Payroll
Terms and Conditions
I understand that my membership, and if applicable, my direct debit payments, will automatically be reactivated on the "End Date". Please note, for direct debit memberships, your 12 month minimum term date will be extended according to the length of your suspension. Please allow 48 hours for processing.
I have read and understood these terms and conditions
Please enter any additional instructions or comments: