Name:

Membership No.:

With effect from: AugustSeptemberOctoberNovemberDecemberJanuaryFebruaryMarchAprilMayJuneJuly 20102011 I would like to (Change Membership Status) (Freeze Membership)

Current Membership Status:

Current Payment: £ per month (If known).

New Membership Status:

New Payment: £ per month (If known).

I understand my new direct debit will now be £ per month with effect from AugustSeptemberOctoberNovemberDecemberJanuaryFebruaryMarchAprilMayJuneJuly 20102011 (If known).

I would like to freeze my membership for a period of 1 2 3 4 5 6 Month(s).

( - I understand that my monthly dues will revert back to normal rate at the end of the freeze period.)

Notes:

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Westside will contact you to confirm your submitted details.