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2. Customer Information
4. Customers Name:*
6. Service Address*
   Address where service is being discontinued at
8. Home Phone
9. Work Phone
11. Cell Phone*
12. Email Address
14. Date of Disconnect:*
    Date of Disconnect:

    Connects and disconnects will not be completed on weekends or city observed holiday's. For a list of city observed holidays visit https://www.robinsontexas.org/652/City-Observed-Holidays. If you choose a date that falls on a weekend or city observed holiday, the connection will not be made until the next following business day.

16. Does your utilities account include any additional carts over the one (1) solid waste and one (1) recycling cart that comes standard with City of Robinson solid waste services?*

    1. Yes
    2. No
17. Provide the # of Trash Carts:*
18. Provide the # of Recycling Carts:*
20. Last Bill Information
22. Name:*
24. Forwarding Address:*
    This needs to be a good mailing address that mail can be sent to once services have ended.
26. City:*
27. State:*
28. Zip Code:*
30. Customers Acknowledgement
32. BY PROVIDING YOUR NAME BELOW, YOU ARE CERTIFYING THAT THE INFORMATION THAT YOU HAVE PROVIDED HEREIN IS TRUE AND CORRECT.*
    AGREED AND UNDERSTOOD:
34. Relationship to the account holder (if you are not the account holder making the request):

    1. Spouse
    2. Other
35. If other, provide who:
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field