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2. Customer Information
4. Customers Name:*
5. Account #:*
7. Service Address*
   Address where service is being discontinued at
9. Home Phone
10. Work Phone
12. Cell Phone*
13. Email Address
15. Effective Date:*
    This is the date you would like the cancelation to go into effect.
17. Customers Acknowledgement
19. BY PROVIDING YOUR NAME BELOW, YOUR ACKNOWLEDGING YOU WOULD LIKE TO CANCEL AUTOMATIC DRAFT FOR THE ACCOUNT # LISTED AT THE BEGINNING OF THIS APPLICATION AND YOU ARE CERTIFYING THAT THE INFORMATION THAT YOU HAVE PROVIDED HEREIN IS TRUE AND CORRECT.*
    AGREED AND UNDERSTOOD:
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field