Utility Termination of Service

Utility Termination of Service

Please fill out this form to provide your consent for terminating utility services.
Full Name:*

First NameLast Name
Account Number:*
Phone Number:*
Email:*
example@example.com
Service Address:*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Termination
PLEASE ALLOW 1 BUSINESS DAY NOTICE FOR ANY SERVICE ORDER REQUEST

$25 + TAX FEE WILL APPLY TO REINSTATE SERVICE

**PLEASE NOTE: TIME OF DISCONNECT CAN BE ANY TIME BETWEEN 6AM AND 5PM ON DATE INDICATED**
Date of Termination*

MonthDayYear
Is this a turn permanent off or temporary turn off?*

Permanent off (to close account)Temporary off (i.e. vacation)
CAN ONLY TERMINATE SERVICE MONDAY-FRIDAY (CLOSED ON HOLIDAYS**)

**CONTACT UTILITY BILLING FOR HOLIDAY DATES
Forwarding Address:*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Your Signature: Signature *
Should be Empty:

Termination