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2. Disconnect Date*
3. **Payment for current balance due at time of Service Disconnection**
5. First Name*
6. Last Name*
8. Email Address*
9. Phone #*
11. DL #*
12. Date of Birth*
14. Service Address
16. Address1*
18. City*
19. State*
20. Zip*
22. Forwarding Address
24. Address1*
26. City*
27. State*
28. Zip*
32. I understand that*

    1. there will be a final bill for service for base rates and usage through the disconnection date.
33. I understand that*

    1. if I have not already received my deposit as an account credit, my deposit will be applied to the final bill and any past-due balance.
34. I understand *

    1. I will be refunded any remaining amount of the deposit, which will be mailed to the forwarding address I have provided above.
36. ***All delinquent accounts will be sent to McCreary, Veselka, Bragg & Allen, P.C. Attorneys at Law.
40. Signature
    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.
42. I agree to the above statement and confirm that all the information on this application is true and accurate to the best of my knowledge.*

    1. I AGGREE
44. Signature: First M. Last
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field