Signed date: Staff signature: Date received: -End of form- Office use only Customer number Contract Number Contract Start Date Contract Expiry Existing Membership Details New Membership Details Total # Type Duration Total # Days Cost Type Duration Cost Days Months Months Total Cost Total Days Cost per day Total Cost Total Days Cost per day ÷ = (A) ÷ = (A) Pro Rata Fee – (Member required to pay total E) Total Days Remaining on Existing Expiry Effective Date of Requested Change Membership (C) Total (B) Total (A) Total (D) Total (C) PRO RATA FEE - = (D) x = (E) Membership Type Changed Pro Rata Adjustment Made Date Processed in Links Processed By
Signed date: Staff signature: Date received: -End of form- Office use only Customer number Contract Number Contract Start Date Contract Expiry Existing Membership Details New Membership Details Type Duration Total # Days Cost Type Duration Total # Days Cost Months Months Total Cost Total Days Cost per day Total Cost Total Days Cost per day ÷ = (A) ÷ = (A) Pro Rata Fee – (Member required to pay total E) Existing Expiry Effective Date of Requested Change Total Days Remaining on Membership (C) Total (B) Total (A) Total (D) Total (C) PRO RATA FEE - = (D) x = (E) Membership Type Changed Pro Rata Adjustment Made Date Processed in Links Processed By