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Account Cancellation Form

THIS FORM IS REQUIRED FOR CANCELLATION. PLEASE FILL OUT ALL PERTINENT INFORMATION. YOU MAY SUBMIT THE INFORMATION ELECTRONICALLY BY CLICKING THE SUBMIT BUTTON, OR ALTERNATIVELY, YOU MAY PRINT THE FORM OUT AND SUBMIT IT VIA FAX OR UNITED STATES POSTAL SERVICES. YOUR SERVICE/SERVICES WILL BE CANCELLED WITHIN 30 DAYS UPON RECEIPT OF THIS FORM.
Customer Information

I , would like to cancel my account effective

(Note: cancellations must be dated no sooner than today's date: 09/09/2010)

I certify that I am the owner of this account.
I understand that I will not be reimbursed for any prorated services
and that this cancellation is a 30 DAY NOTICE cancellation.
Company Name:   
Phone Number:   
Email Address:   
 
Services to be cancelled
Dialup DSL
Hosting Other
 
Drizzle domain name(s) to be cancelled:
Drizzle username(s) to be cancelled:
Drizzle password to be cancelled:
(Note: the password is required to help confirm your authority to make this cancellation request)
 
Billing Information
Billing Address   
City   
State   
Zip Code   
 
We would appreciate your comments regarding our services and support.
Please let us know the reason you are canceling your account.

You will receive a cancellation confirmation via e-mail

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