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 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

Date

Date to disconnect old address (moving from)

Earliest AvailableSpecify Date (below)

Disconnect Date (moving from)

Date (max 7 days from Connect or Transfer Date)

Day(s) between connect and disconnect

max 7 days

Full Name

First NameMiddle NameLast Name

Company Name

Current Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

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

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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.

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

Social Security Number

Information can be provided at the time of setup.

Date of Birth

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

Valid, Unexpired Photo ID¹ (residential) or Articles of Incorporation (for commercial).

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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.

Please provide a purchase, lease, rental agreement or supporting documentation.

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Comments

Authorized Signature*

Clear

Name*

First NameMiddle NameLast Name

Date*

Hour MinutesAM/PM Option

Customer Service Request

Contact Information

Transferring Services To:

Draft Authorization

Additional Information

Confidential Information

Required/Requested Documents

Additional Information

Signature