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Electric Disconnect Service Request Form

Stop Service- Electric Disconnect Service Request Form

Date of Disconnect

(Business days only. Can not be weekends or holidays)

Member First Name:

Member Last Name:

Phone Number:

E-mail Address

(Please enter the applicant email address)

Please select the the water service option that applies to you:

Would you like your Cullman County Water Account disconnected?

Please contact your water provider directly to disconnect water services

Please contact your water provider directly to disconnect water services

Account to Disconnect

Account Number:

Service Address/E-911 Address

Unit, Lot, Apt. Number, etc.

City

State

ZIP Code

Do you plan to move or demolish the current structure at this location?

Forwarding Address:

Street Address

Unit, Lot, Apt. Number, etc.

City

State

ZIP Code

I understand that checking this box and typing my name in the field provided below is my electronic signature.*

Applicant Signature

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