Customer Cancellation form

Service Cancellation

Thank you for using our service. To help us understand why you decided to cancel, please provide us with feedback by filling in the information below.

First Name *

Last Name *

Account Number

Street Address *

Address Line 2

City *

State

Zip Code *

Phone Number *

Email Address *

What is your reason for cancelling? *

Moving

Disatisfied

Other

If you are moving within our service area and would like to continue at your new address, please list it here and we will make the change when you are ready.

Please briefly explain why you are canceling. *

What could we have done differently that would have kept you from canceling?

Do you plan on replacing this service with a similar service provided by a different company, or discontinuing this service altogether? *

Switching to another company

Discontinuing altogether

Please rate the following aspects of our service. *

	Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Dissatisfied
Customer Service	Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Dissatisfied
Price	Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Dissatisfied
Quality	Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Dissatisfied
Speed	Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Dissatisfied

Compared to other services of this type, how would you rate our service? *

Superior

Equal to

Less than

Haven't used another service

Overall, how satisfied were you with our service? *

Should we be able to address your concerns to your satisfaction would it have an impact on your decision to cancel *

Yes

No

Would you recommend this service to others? *

Yes

No