First Name
*
Last Name
*
Phone Number
*
Format: (000) 000-0000.
Email
*
Confirmation Email
Service Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Date to disconnect service
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Service must be disconnected on a weekday. If a weekend date/holiday is selected, service will disconnect on the prior business day.
Suspend all services?
*
Yes
No
Which services do you want to suspend
Internet
Cable TV
Telephone
Do you have a different mailing address?
*
Yes
No
Mailing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Notes
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Yes, I am requesting that Corn Belt Telephone disconnect my services indicated above, on the date indicated above. I understand that if I have chosen a non business day for service to resume, service will be re-activated on the prior business day. I understand that billing for these services will resume on the date I have indicated above.
*
Confirm
*
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