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Name*
First Last
Email*
Person Requesting Termination of Service*
If name is not on account, please enter relationship
Account Number*
Current Daytime Phone Number*
Current Home Phone Number
Effective Date of Termination*
Date Format: MM slash DD slash YYYY
Forwarding Address for Final Bill
Street Address Address Line 2 City State ZIP Code
Are you moving to another location that BWC serves?*
- Yes
- No
What is the address?
Street Address Address Line 2 City State ZIP Code
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