Fillable Service Transfer Request Form (City of West Memphis)

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Service Transfer Request Form (City of West Memphis)

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WMUC, STR Form, Revised 8/12
Service Transfer Request Form
In accordance with WMUC policy any past due balance on your current service address must
be paid in full before service can be transferred. Additionally, a $20 transfer fee will be added to
your next bill.
CURRENT ACCCOUNT INFORMATION (PLEASE PRINT)
Name on
Account:____________________________________________________________________
Service Address: _____________________________________________________________
Phone: ____________________________ Social Security #: _________________________
Person Requesting Transfer: ______________________Turn Off Date: _______________
FOR OFFICE USE ONLY
Received By: __________________ Date: _____________
Completed By: _______________ _ Date: ____________
AVO#: _____________________________ Date Turned Off: ________________
NEW SERVICE ADDRESS (PLEASE PRINT)
Street: _____________________________________________________________________
City: ____________________ State: _____________________Zip Code: _____________
Signature: ___________________________________________Turn On Date: ____________
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Service Transfer Request Form (City of West Memphis)

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Completed 25 January 2021

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