2. Request may only be submitted by the account holder. Otherwise, it will be considered invalid.
4. Account #*
5. Date to Disconnect*
   Date to Disconnect
   ***Cannot disconnect same day or on weekends.***
   Cannot schedule more than two weeks in advance.
7. Name*
8. Phone Number*
10. Service Address to Disconnect*
14. Fowarding Street Address*
16. Forwarding City, State, & Zip Code*
18. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) you are the account holder and are thereby authorized to disconnect service, 2) signature of anyone other than the account holder will be deemed invalid, 3) your application will not be signed in the sense of a traditional paper document, 4) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 5) you may still be required to provide a traditional signature at a later date.

    1. I agree.
20. Electronic Signature*
21. Date*
    Date
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field