Client Change Form

Customer Information -

Date / Time

First Name

Last Name

Type of Change

New Customer

Renewal

New Credit Card

Cancellation

New Customer -

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Mobile

Email

Registration Fee

Number of Hours

Rate Per Hour

Total

Payment Plan

Yes

No

Number of Payments

Payment Amount

New Card Type

Card Number

Expiration

CSV/CVV Code

Renewal -

Number of Hours

Rate Per Hour

Total

Payment Plan

Yes

No

Number of Payments

Payment Amount

Use card on file?

Yes

No

If you are using the card on file, make sure the card is not expired and they have not moved. You can check for the past card information on Oases in the notes section.

New Card Type

Card Number

Expiration

CSV/CVV Code

New Credit Card -

New Card Type

Card Number

Expiration

CSV/CVV Code

Refund -

Original Number of Hours

Number of Hours Used

Cancellation Fee?

Original Rate Per Hour

New Rate Per Hour

Contracted Total

Adjusted Total to Dragonfly

Total Refund

Additional Instructions -

Comments