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2. Name on Account *
4. Customer Service Address *
6. Disconnect Date Desired *
   Disconnect Date Desired

   (Excluding weekends/holidays. Submissions after 3 pm will need to be scheduled for the following business day). 

8. Mailing Address (For Final Bill / Refunds) *
10. Are you currently enrolled in Bank Debit? If so, do you wish to continue for the new service address?

    1. Yes
    2. No
12. New Service Address to Connect *
14. Residential Application
15. Aplicación Residencial Española
16. Commercial Application
18. Upload Residential Application
19. Upload Commercial Application
20. Upload Rental Agreement/Deed-Purchase Contract
22. Service Connection Date Desired *
    Service Connection Date Desired

    (Excluding weekends/holidays. Submissions after 3 pm will need to be scheduled for the following business day).

24. Mailing Address (If Different From Service Address) *
26. Best Contact Number *
28. Email Address (If Applicable)
30. Additional Comments
32. Consent

    1. I Agree

    A Customer Service Representative will contact you at the number provided if any other documentation or payment is required.

    I acknowledge the above-stated information is correct.

    If you need to make changes to your submitted form, contact our office immediately at 620-276-1100. Fees may apply if you wish to cancel this request after it has been processed.

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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field