Payment Adjustment Request Form

We acknowledge your request to change your Shadow Work Advanced Practitioner membership Payment Frequency. Please complete the form below so we can process your request quickly and accurately.

Full Name *

Note: Please enter the EMAIL ADDRESS you used to sign up for the Advanced Practitioner Program.

Email *

Payment Adjustment Request Details

I would like to request a change to my payment frequency or amount for the remaining term of my contract. Please select your preferred option below:

Current Payment Frequency *

Weekly

Fortnightly

Monthly

Requested Payment Frequency *

Weekly

Fortnightly

Monthly

Adjust Payment Amount

Please select one of the following payment options:

Transaction Fee:
2.66% for Credit Card (CC)
1% for Direct Debit (DD)

Weekly Payment Adjustments *

$50 Weekly (up to 12 weeks), then increase to $100 Weekly

$100 Weekly

$150 Weekly

Fortnightly Payment Adjustments *

$100 Every Fortnight for 6 Fortnights, then increase to $200 Every Fortnight

$200 Every Fortnight

Monthly Payment Adjustments *

$200 Every Month for 6 Months, then increase to $400 Every Month

$400 Every Month

Payment Method Selection

Payment Method Selection *

Credit Card (CC)

Direct Debit (DD)

Terms and Conditions

Payment adjustments are subject to approval based on the terms of your contract.
Adjustments to the payment frequency or amount may extend the overall contract duration.
The new payment amount and frequency will apply from the next scheduled payment.
Requests for payment adjustments must be submitted at least 14 days before the next payment due date.
Transaction Fees:
- Credit Card (CC): 2.66% per transaction.
- Direct Debit (DD): 1% per transaction.

Signature

Signature *

Clear

Date *