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2. EFT Membership Cancellation Form
   Jack E. Kirksey Recreation Center   (734) 466-2297

4. Member Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Daytime Phone Number
15. Customer Comments
17. 1. I understand it takes up to 30 days to stop payment from the date of this cancellation.
    2. I authorize the City of Livonia to stop deduction from my check/savings account or credit card. 
19. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
21. Electronic Signature
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field