Service Disconnect

Service Type to be Disconnected

Name*

First Middle Initial Last

Business Name*

Contractor Name*

Phone*

Account*

Meter #:

Email*

Service Address*

Address where you receive electrical service from Nodak Electric

Street Address Address Line 2 City State ZIP Code

Do you own or rent this property?*

Own
Rent

Rental/Leasing Agency:*

Rental/Leasing Agency Phone #:*

Last Date of Occupancy*

(Last day I am responsible for purchasing electricity)

Forwarding Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Did you work with a Realtor?*

Yes
No

Realtor Company Name*

Realtor Name*

Realtor Phone Number*

Do you know the name/phone of the new occupant?

Name of New Occupant (if known):

Name

Phone # of New Occupant (if known):

Hidden

Signature*

By signing below, I acknowledge that I am planning to move out of my current residence, thus transferring responsibility for electric service, on the "Last Day of Occupancy" as stated above.

Name of Signee*

First Last