Service Request

First Name (required)

Last Name (required)

Your Email (required)

Best Phone Number

Company (if not residential)

City where work is to be performed

Customer # (if available)

Work to be performed:
Check Meter CenterCheck Overhead ServiceShorted CircuitEmergency ServiceOther/Unknown

Work to be performed if requesting DataComm service:
Add Data OutletAdd Phone OutletInstall Data/Phone OutletEmergency ServiceOther

Brief description of work needed

Preferred Service Date

Time of Service Preferred
Early MorningLate MorningEarly AfternoonLate AfternoonAnytime

Payment Method
*Bill Me**Visa/MastercardCash/Check

*Existing accounts only. Terms: net 30 days
**Give Credit Card to Service Tech upon completion of service