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: - Select -Cullman County WaterOther Would you like your Cullman County Water Account disconnected? - Select -yesno 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 - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Do you plan to move or demolish the current structure at this location? - Select -yesno Forwarding Address: Street Address Unit, Lot, Apt. Number, etc. City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code I understand that checking this box and typing my name in the field provided below is my electronic signature.* Applicant Signature Reset Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
