Request for Service Disconnection
NOTE: Fields marked * are required.

*Member Name:
Please enter the last 4 digits of your Social Security Number (SSN) or Employer Identification Number (EIN).
*Last 4 Digits of SSN or EIN:
*Service Address:
*Current City:
*Current State:
*Current Zip:
*Account Number:
*Phone Number:
*Email Address:
*Disconnect on:    
Do you currently have active service at another WKRECC location?
*Other WKRECC Active Service?:
Forwarding Information for Final Bill
*Forwarding Address:
*Forwarding City:
*Forwarding State:
*Forwarding Zip:
This request is for a regular disconnection of service, and I am responsible for all charges through the date of the disconnect that will be provided to me on the final bill.

I certify that I am the person stated above and that I authorize the service at the above address to be disconnected, and I agree to accept all responsibility for and to release, indemnify and hold harmless WKRECC for any claims related to the disconnect.

Click here to draw your signature.

Customer Signature
With your mouse, draw your signature. Then click Finish.

*Date: (MM/DD/YYYY)