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2. Please Read:
   *** This action permanently removes the current property owner information. If you later choose to have the property placed under your name again, a new application will need to be completed and appropriate fees paid prior to re-connection of service.
4. Name*
   Only the individual whose name is listed on the account (or, in the case of a commercial account, a current representative of said business) is authorized to cancel service. If the information provided does not match the account, the request will not be processed.
6. Service Location*
   If you have more than one account, such as irrigation, etc., you will need to complete one form for each account and specify.
8. Forwarding Address*
10. Forwarding Address City*
11. Forwarding Address State
12. Forwarding Zip Code*
14. Date To Final Service*
    Date To Final Service
16. Please Note:
    We schedule by date only - we cannot schedule a specific time but they are normally done first thing in the morning. If this is not convenient for you, you will need to date your final service for the next business day. Final service can be performed the next business day after we receive the completed form in our office or later if you prefer. Forms received after hours will require an additional business day. Do not backdate your form - service is billed on manual readings, not proration. No services will be scheduled on holidays or weekends. If you enter a holiday or weekend date, it will be scheduled for the next business day after that date.
18. 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.

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


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

    This field is not part of the form submission.

24. Submit Submit and Print

* indicates a required field