LUCHF Cancellation Form

* Denotes required field
*	Member ID
	Request Date	11/21/2009
	Effective Date	12/31/2009
	Final Workout Date	12/31/2009
*	First Name
*	Last Name
*	Home Phone
	Work Phone
*	Email Address
*	Cancellation Reason
	Comments
	Rental Locker
*	Lockers
	Loyola Employee
	Social Security Number
	Have you read the cancellation notice?
	Have you read the authorization notice?