Name:

Membership No.:

Address:

Postcode:

Telephone No.:

Membership cancelled with effect from: AugustSeptemberOctoberNovemberDecemberJanuaryFebruaryMarchAprilMayJuneJuly 20102011

The staff at Westside would appreciate it if you would take a few moments to complete this Membership Resignation Form. Any comments you make will assist us in providing a better Club and service in the future, and would be greatly appreciated! Thank you for your feedback and for allowing us to serve you here at Westside Health & Fitness Club.

1) What was your overall rating of Westside Health and Fitness club? 5 (Highest) 4 3 2 1 (Lowest)

2) Why did you resign from Westside?

3) What did you enjoy most about the club?

4) Please state any aspects of the club you feel could be improved:

5) Did you leave because you were dissatisfied with some aspects of the Club? (Yes) (No)

Please specify which aspects you were dissatisfied with:

6) Are there any conditions under which you would re-join?

By clicking submit you confirm you will cancel your monthly direct debit with your bank and will not hold Westside responsible for any subsequent payments which are processed due to your failure to do so!

Westside will contact you to confirm your submitted details.