MemberNetTV Cancellation Form

Company & DBA*

Contact Name*

Email*

Phone*

To Cancel All Machines, Check Here:

To cancel select machines, enter MNTV IDs:

This 3 to 4-digit number can be found labeled on the side/bottom of the machine, or by using the remote and accessing Settings > About

Date Effective (If cancelling for future date)

NOTE 1. Your original Order Form/Subscription Agreement supersedes this cancellation submission; that commitment requires you to pay the monthly subscription fees for 120 days or return the MemberNetTV hardware to Nationwide.

Initial Here For Note 1*

2. The changes in your monthly billing take affect for the calendar month following this submission. If you entered a future cancellation date above, changes will take affect for the calendar month’s billing following that date.

Initial Here For Note 2*

Reason For Cancellation

Additional Comments

If you are returning machines, please check the box below to receive an email confirmation.

Send me a copy of my responses

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