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2. Primary Account Holder
4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address
10. Is there a Secondary Account Holder?*

    1. Yes

    1. No
12. Secondary Account Holder First Name
13. Secondary Account Holder Last Name
15. Secondary Account Holder Phone Number
16. Secondary Account Holder Email Address
20. Service Address
22. Address Line 1*
24. Is your mailing address different from your service address?*

    1. Yes

    1. No
26. Mailing Address Line 1
28. Mailing Address Line 2
30. Mailing City
31. Mailing State
33. Mailing Zip Code
35. What date do you wish to change services at the above address?
    What date do you wish to change services at the above address?
39. Services I would Like Added or Changed

    1. Electric
    2. Water/Sewer
    3. Garbage

    1. Skitter TV / Acclaim
    2. Internet
    3. Phone
40. Services I Would Like Stopped

    1. Electric
    2. Water/Sewer
    3. Garbage
    4. All Services

    1. Internet
    2. Skitter TV
    3. Phone
42. Do You Want Additional Garbage Totes?

    1. Yes
    2. No
43. Do You Want Recycling Tote(s)?

    1. Yes
    2. No
45. Do You Want Garbage Totes Removed From The Service Address?

    1. Yes
    2. No
46. Do You Want Recycling Totes Removed From the Service Address?

    1. Yes
    2. No
48. Number of Garbage Totes Requested
49. Number of Recycling Totes Requested
51. Number of Garbage Totes You Would Like Removed
52. Number of Recycling Totes You Would Like Removed
54. Internet Service:

    1. Cable Modem - $49.99/mo
    2. GIG Fiber Residential - $59.99/mo
    3. GIG Fiber Business - $79.99/mo
56. Skitter TV Packages:

    1. Acclaim Lite - $45.00/mo
    2. Acclaim Choice - $70.00/mo
    3. Acclaim Choice+ - $75.00/mo
    4. Prime - $119.99/mo
    5. Total - $129.99/mo
    6. Business - $69.99/mo
57. Premium Skitter Channels Add-Ons

    1. HBO - $20.00/mo
    2. Cinemax - $14.00/mo
    3. STARZ - $12.00/mo
    4. STARZ Encore - $7.00/mo
59. Sports Package

    $8.00 with Select or Prime Package or $6.00 with Total Package. Includes NFL Network, NFL RedZone, Fox College Sports, Fantasy Sports, Fight Network, and Outside TV.

    1. Sign-Up
    2. No Thank You
61. Number of Skitter TV Set Top Boxes Needed ($4.99 each)
63. Phone Packages:

    1. Unlimited Residential - $29.95/month
    2. Unlimited Business - $44/month
65. Current Phone Provider
66. Current Phone Contract
67. Keep or Change Old Number

    1. Keep
    2. Change
69. Reasons for Stopping Service(s)
71. Forwarding Address Line 1

    The forwarding address will be used to send your final bill or deposit refund.

73. Forwarding Address Line 2
75. Forwarding City
76. Forwarding State
78. Forwarding Zip Code
80. Acknowledgement

    We will contact you at the phone number you have provided to complete the process of your service request. 

84. *See RRR for fees/deposits associated with establishing new service.
    Click Here
86. Activation and Installation fees may apply for new services.
88. Telecom equipment must be returned upon cancellation of services. Your account will be billed for equipment that is not returned.
90. If this form does not cover your request, please feel free to contact CBPU at 517-279-9531, Monday-Friday, 8:30 a.m. to 5:00 p.m.
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit

* indicates a required field