Membership Hold Form Not A Termination Request Form must be submitted at least 5 business days before next draft date for changes to be effective for that draft date. Membership Hold Form MEMBER FIRST NAME: * MEMBER LAST NAME: * EMAIL: * HOLD START DATE: * HOLD END DATE: * Per BRICK policy, all members have the option to put their membership on a one (1) time, per 12 month period, for up to three (3) consecutive months. Members with a prepaid plan are not eligible to submit a hold. Upon expiration of the term of the hold, member’s account will automatically become active and payments shall resume. Should member choose to return prior to the end of their hold period, the hold will be released, payments will resume and they will NOT be entitled to submit another hold during the same twelve (12) month period, regardless of what amount of time is remaining on their hold request. Should member elect to cancel during the hold period, they must submit an electronic cancellation form. The 14-day Cancellation will begin upon submission of the cancellation form. The submission of a Hold Form effectively halts the member’s contract period and the contract term will resume upon the release of the member’s hold period. REASON FOR HOLD: * Injury/Illness Location No Longer Convenient Financial Burden Dissatisfaction With Service Other By submitting this form I agree to abide by the following guidelines regarding my request to place my membership on hold: I understand that my draft will automatically restart after my hold period. Submit If you are human, leave this field blank.