1. Please enter your real estate agent's name, office location, and phone number if known:

	Agent First Name:
	Agent Last Name:
	Office Location:	(city, street/neighborhood)
	Agent Phone Number:	( ) - ext:

2. Please check the services you would like:

The customer service representative who contacts you will be able to discuss these services, pricing and promotional information with you. Choosing a service now does not obligate you to accept the service later. Talk with your customer service representative about which services best fit your needs.

Disconnection Services Electrical Service   Gas Telephone   Waste Removal Water and Sewer   Television Service           Connection Services Electrical Service Gas Local Telephone Long Distance Telephone Cellular Telephone Water and Sewer Waste Removal Newspaper Delivery   Television Service Internet Access Home Security Lawn Care & Landscaping Pest Control Moving Service Bottled and Filtered Water U.S. Mail Change of Address Would you like us to notify the post office of your change of address?      Yes       No Are all members of the household moving?      Yes       No

3. Please complete the following information for change of service:

To make your change of address, connections, disconnections and transfers of service as simple as possible, all you have to do is take a few minutes to fill out the information requested below. A Service Representative will contact you about your needs. Note: The primary head of household should be in Contact A below. Contact Name:   Contact A: Contact B: First Name: Middle Initial: Last Name: Social Security Number: Contact Information (for person listed in Contact A above): Evening Phone: ( ) - ext: Daytime Phone: ( ) - ext: Fax Number: ( ) - Pager Number: ( ) - Cellular Phone Number: ( ) - Email:   In the event service representative cannot reach Contact A, Contact B will be called. Contact B Daytime Phone: ( ) - ext: Current Address: Street Address 1: Street Address 2: City/State/Zip: / / Employer Information (for person listed in Contact A above): Name: Phone: ( ) - ext: New Address: Street Address 1: Street Address 2: City/State/Zip: / / Current occupant of your new residence (if known): Name: First:    Last: Phone: ( ) - ext: Person buying your current residence (if known): Name: First:     Last: Phone: ( ) - ext: Effective Dates: Move Out Date: (MM/DD/YYYY) This is the date your utilities will be scheduled to be turned off. Move In Date: (MM/DD/YYYY) This is the date your utilities will be scheduled to be turned on.

4. Verify and submit your request:

Please check this form for accuracy, then click the "Submit Form" button below. If you have any questions, or have not heard from a service representative within 2 business days, please call our office at 919-524-2898.