Cancellation of Referral Services

I believe I have a CHOICE in the referral or placement service I choose to work with. Unfortunately, I understand that sometimes people have no knowledge when their information is being used for commercial use and given to many senior housing communities to establish a "First Position" for referral compensation.

I also believe that I have the CHOICE to work with a service that performs a better quality of search.

THEREFORE, I hereby immediately cancel, revoke and/or terminate any actual or implied agreement between me and (TYPE IN TERMINATING AGENCY NAME) *

City, state and zip code of the terminating agency:

City *

State *

Zip Code *

Name Of The Agency or Agent I Choose To Represent Me Is *

Email Address Of The Agent or Agency *