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Request for Termination of Services

2. 

4. 

6. Customer Name*

7. Customer Phone Number*

9. Driver's License Number*

10. Email Address*

12. Address for Termination*

13. Date for Termination*

15. Forwarding Address*

    Include City, State, Zip

17. Customer Acknowledgement of Termination Date*

    1. I agree

    Customer understands the electric service may terminate at 12 am on the date entered. It is recommended to select the first date you will not be in the residence as the termination date. Any service calls due to disconnection at midnight will result in a $65 after hours fee.

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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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