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Please Enter Needed Information and Desired Action
Cancel USAV Membership and Request Refund
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Participant Info
•Participant Legal Name  •First:    •Last: 
  •Participant USAV Number:
•Participant Date of Birth: Open Calendar
  •Reason for Request:
Refund Payee Info
Refund Limited to Membership Fee Only
Background Screening Fee and $2.00 Convenience Fee Not Refunded
•Refund Payee Legal Name  •First:    •Last: 
•Refund Payee Street:
•Refund Payee City:
•Refund Payee •State:                •  ZIP:    ZIP+4: 
•Refund Payee Email:
•Refund Payee Phone: - -   xt
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