EFT only FREEZE REQUEST FORM

All Freezes must start on your Bill Date and end on the day before the next Bill Date (the last day of the month or 14th of the month). The soonest your Freeze may start is on your next Bill Date, given 15 days advanced notice.

Your Name (required)

Your Email (required)

Please leave this field empty.

Your Phone

Your Bar Code Number

From Date

30 days60 days90 days

Reason for Freeze (EFT only)
—Please choose an option—Work relatedMedical relatedPersonal

15 DAY FREEZE REQUEST NOTICE*:
By checking this box and clicking the "Submit" button on this page, I acknowledge that the freeze request can take up to 15 (fifteen) days to be processed. I further acknowledge that if my next scheduled billing date is less than 15 days from the submission date of this form, I MAY be billed as per terms outlined in my contract.

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