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Service Disconnection/Removal

*Required

Department and Billing Information

Department Name: *
Department Number
Monthly FRS Code: *
One-Time FRS Code: *
UConn Campus:  
Department Head's Name:  
Has the department head authorized this request? * Approval is required.  By indicating "yes", your department agrees to pay for all charges that pertain to this request.

Contact Information

Contact's Name: *
Contact's Telephone #: *
Contact's E-mail: *

Subscriber Information

Change this section ONLY if you want to change how the listing appears on the monthly invoice.

Subscriber's Name:
Name on the phone bill:		  First: Last:
Subscriber's E-Mail:

Telephone to be Disconnected

Telephone Number: *
Building Name *
Room Number *
Jack Number *

What is to be Disconnected?

SINGLE LINE SET Desk
Wall
Speakerphone
MULTILINE SET 10 Button
24 Button
LINE ONLY: (No phone set) Modem
Fax
Secondary
Call Forward Remote
Other: (Please Specify)

Comments:




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Updated: 6/28/2007