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2. Requested Disconnection Date*
   Requested Disconnection Date

   (On or After)

4. Account Holder's Full Name*
6. Account Number*
8. Address*
10. City*
11. State
12. Zip Code
14. Phone Number*

    In case we need to contact you while you are away. 

15. Email Address

    In case we need to contact you while you are away.

17. I understand......
    • that my electric and water services will be disconnected either on or after the date requested. 
    •  no charges will accrue, and my deposit will be held in escrow until I return. 
    • the account may remain on vacation turn off status for a minimum of 90 days and a maximum of 180 days. Residents can utilize this service only one time in a twelve-month period.
    • that there is a $20 reconnection fee for this option.
    • that I must give at least a seven-day notice before returning to allow for reconnection scheduling.
    • that the City of Bartow is not responsible for any electrical or water damage that may occur while I am away.
21. Customer's Signature*
22. Acknowledgement /Consent*

    1. This is My Signature / I Agree

    By Checking this box, I acknowledge all information provided is true/correct including my provided signature and that I have read, understand and agree to the terms and conditions of this application.

    
    

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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit Submit and Print

* indicates a required field