RecWell Membership Action
Contact Information
First Name
Last Name
Email
Phone
Department
Case Information
The Membership Hold fee for monthly members is $10/month, for up to 6 months. Annual members pay $30 for a hold up to 6 months. Membership Hold requests are limited to one hold per year.
The membership billing cycle runs from the first of the month through the end of the month. Monthly membership cancellation requests must be received by the 25th of the month in order to avoid being charged for the following month.
If a cancellation request is received after the 25th, the member will be responsible for the following month’s membership fee.
Request Type
Affiliation
ID Number
Start Hold
Please enter as MM/YYYY.
End Hold
Please enter as MM/YYYY.
Refund Type
Pay Cycle
Effective Date Needed
Type
Subject
Please provide a brief description or reason for your request.
File Upload
File Upload
Salesforce Record IDs (All these fields should remain hidden)
Case ID
Contact ID
Record ID
Account ID
For security purposes, do not include any private information in this form such as credit card, social security numbers, or private health information.
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.