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Service Disconnection Form

  1. **Payment for current balance due at time of Service Disconnection**

  2. Service Address

  3. Forwarding Address

  4. I understand that*

  5. I understand that*

  6. I understand *

  7. ***All delinquent accounts will be sent to McCreary, Veselka, Bragg & Allen, P.C. Attorneys at Law.

  8. 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.

  9. 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.*

  10. Leave This Blank:

  11. This field is not part of the form submission.