Stop Service - 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

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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