Customer Service Request

Customer Service Request
Request Type*

New Residential Account RequestNew Commercial Account RequestTransfer Service RequestBank Draft Request or UpdateResidential Customer Information Change RequestCommercial Customer Information Change Request
If you are working with a Customer Service Agent, please type their name.
Account Number (s)
If multiple accounts, separate with a comma.
Date to Connect or Transfer Service (moving to)

Earliest AvailableSpecify Date (below)
Connect or Transfer Date

MonthDayYear
Date
Date to disconnect old address (moving from)

Earliest AvailableSpecify Date (below)
Disconnect Date (moving from)

MonthDayYear
Date (max 7 days from Connect or Transfer Date)
Day(s) between connect and disconnect
max 7 days
Right of Access

Customer agrees to abide by Federal, State, City and CWL rules and regulations governing use of CWL utilities including right of access to customer premises. Refusal to abide by these rules and regulations or refusal to grant access can result in service termination.
Contact Information
Full Name

First NameMiddle NameLast Name
Company Name
Current Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transferring Services To:
Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address Same as Service Address

Billing Address same as Service Address
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
The primary phone number capable of receiving SMS/Text messages

Yes
Would you like to receive SMS/Text message notifications concerning your account?

Yes
There is no fee charged by CWL to send you CWL SMS/text messages. However, you may be subject to service fees by your cell phone carrier to receive them. Fees vary depending on your service plan. You are responsible for any costs associated with receipt of CWL SMS text messages. Contact your carrier for details.
Email
example@example.com
Would you like to receive your bill via email?

Yes
Draft Authorization
Authorize payments via draft

Yes
Statement of Understanding

I understand that any existing account balance will NOT draft and must be paid by customer.
Name of Bank or Financial Institution
Statement of Understanding

I understand if a voided check (not deposit slip) must be uploaded.
Draft Options

Your regular due date (18 days after the billing postmark date)3rd Day of the Month following the billing datePick your draft date (some date restrictions apply based on service address)
Draft Day
Upon setup, if there is a problem with the selected date, a customer service representative will contact you.
Upload Voided Check

If a voided check is not uploaded and there is an error with the bank draft, the customer may be responsible for any fees that may be incurred.
Cancelof
Additional Information
List all adults over 18 that can make changes to this account. If residential customer, adults must be living at the residence.
Adult 1

First NameMiddle NameLast Name
Adult 2

First NameMiddle NameLast Name
Adult 3

First NameMiddle NameLast Name
Adult 4

First NameMiddle NameLast Name
Adult 5

First NameMiddle NameLast Name
Adult 6

First NameMiddle NameLast Name
Confidential Information
Social Security Number
Information can be provided at the time of setup.
Date of Birth

MonthDayYear
Information can be provided at the time of setup.
Tax ID
Information can be provided at the time of setup.
President or Owner of Company

PrefixFirst NameMiddle NameLast NameSuffix
Required/Requested Documents
Valid, Unexpired Photo ID¹ (residential) or Articles of Incorporation and W9 (for commercial).

¹ Required photo ID must be issued from a US Government Agency or US State Agency. Examples include, but not limited to: Arkansas Drivers License, US Passport, US Visa, US Military ID, etc.
Cancelof
Please provide a purchase, lease, rental agreement or supporting documentation.

Cancelof
Additional Information

Let us know if there is additional information for this request.
Comments
Signature
Authorized Signature*

Clear
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear

Hour MinutesAM/PM Option
Should be Empty:

Customer Service Request

Contact Information

Transferring Services To:

Draft Authorization

Additional Information

Confidential Information

Required/Requested Documents

Additional Information

Signature