Customer Intake Form

Home Customer Intake Form

Please complete the form below to submit your request. This helps us route your message to the right team and respond as quickly as possible.

A member of our team will review your submission and respond within two business days.

* Required Fields

* Department

* Name

Position with Business

* Phone Number

* Email Address

Confirm Email

* DL# / Last 4 SSN

Residential Request Type

Commercial Request Type

Starting Address

Starting City

Starting State

Starting ZIP Code

Date to Start Service

Are you stopping service?

Yes

Stopping Address

Stopping City

Stopping State

Stopping Zip

Date to Stop Service

Meter Install Date

Forwarding Address

Forwarding City

Forwarding State

Forwarding ZIP Code

Primary Address

Primary City

Primary State

Primary ZIP Code

Is the mailing address the same as the primary address?

Yes

Mailing Address

Account Number (optional)

Amount of Payment

Payment Channel

Date of Payment

Payment Info (Bank Account / Last 4 #'s of Credit/Debit Card)

* Comments

Upload any documents (optional)