2. 
4. Service Disconnection Request

   24 Hour Notice Required - Monday - Friday ONLY

   RENTER ONLY

6. Date of Service to End
   Date of Service to End
8. Billing Name
10. Email*
12. Service Address
14. Forwarding Adddress
16. City
17. State
18. Zip Code
20. Name of Landlord
22. Is your bank account drafted?

    1. Yes
    2. No
23. If yes, do you want the final bill to draft?

    1. Yes
    2. No
25. Please be

    Water could be turned off as early as 7:00 a.m. on disconnection date. Deposit will be returned after 4-6 weeks.

26. Initial Here:
28. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) 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 3) you may still be required to provide a traditional signature at a later date.

    By my signature below, I acknowledge that I have read and agree to the above listed conditions and any questions have been answered satisfactorily. I also understand that the Water service could be turned off as early as 7:00 AM on the disconnection date.

    1. I agree.
30. Electronic Signature
31. Date
    Date
35. Customer Service Representative Signature
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field