CenturyLink - 30 Day Satisfaction Guarantee


Request Form
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Today's Date: 5/16/2012
CenturyLink Installation Date: (mm/dd/yy)
Account Number:
Customer First Name:
Customer Last name:
Service Address:
City:
State:
Zip:
Phone:
Email: (An email copy of the Request Confirmation Form will be sent)

Type of Service:


	Please complete the disconnect survey below.

	Primary reason for disconnecting Prism Service?

		Please Explain:

	What would keep you with CenturyLink?


	Will you consider returning to CenturyLink?
		Yes
		No
		Maybe

	Would you consider receiving special offers from CenturyLink via email?
		Yes, Please enter email address
		No


		*Other fees and conditions may apply. View details.

Request Form