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2. Today's Date / Time
   Today's Date / Time

   Today's Date / Time
4. Customer Account Name
5. Account Number
7. Phone Number
8. Date to Disconnect
   Date to Disconnect
10. Service Address
12. Forwarding Address*
14. City*
15. State*
16. Zip*
18. Electronic Signature

    1. I agree

    By checking I agree, you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.
20. If a disconnection request is received in our office before 2:00 p.m., Monday through Friday, service may be disconnected the same day; otherwise, it will be the next business day before 4:00 p.m.
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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