[usp_name label="Name*"]
[usp_email label="E-Mail*"]
[usp_custom_field form="681741" id="1"]
[usp_custom_field form="681741" id="2"]
[usp_custom_field form="681741" id="3"]
[usp_custom_field form="681741" id="4"]
[usp_custom_field form="681741" id="5"]

[usp_agree label="" toggle=""]I accept the terms of use and agree to the data protection regulations. Moreover I agree that my data will be collected and processed to process your request. Please note: You can cancel your consent for the future at any time by email at [email protected]. Detailed information about use of user data can be found in our privacy policy as well as in our terms of use. 

[usp_submit value="Submit cancellation Request"]

* required Field

[usp_email_alert user="admin" type="submit" subject="User Subscription cancellation Request" cc="[email protected]"]

Thank you!

[/usp_email_alert]