Rt/Seq ______________________
Date of request: _______________________ (Rev: 04/02/15)
TOWN OF ELON
WATER/SEWER SERVICE
(Phone: 336-584-0282) (Fax: 336-584-5334) (Email: elonwater@elon.gov)
Permanent Turn Off Request
TURN OFF: ____________________
(Date)
A/C#: _______________ W/ORDER #: _____________
SERVICE ADDRESS:
_____________________________________________________________
*************************************************************
NAME:
_____________________________________________________________
FORWARDING ADDRESS:
________________________________________________________________________
________________________________________________________________________
Email Address: ________________________________________________
CONTACT PHONE #: (_________) - ____________________
WORK PHONE #: (_________) - ________________________
All of the above information is corrected as stated: _______________________________
Signature
The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this
agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.
