Bartholomew
County REMC
AMPS Cancellation Form
Fax to: 812-372-2112 or mail to P.O. Box 467, Columbus, IN 47202
Name:
Street Address:
City:
State:
Zip:
REMC Account Number (s):
I NO LONGER WISH TO
PARTICIPATE IN THE AMPS PROGRAM WITH BARTHOLOMEW COUNTY R.EM.C.
BY SIGNING BELOW, I HAVE AUTHORIZED REMC TO REMOVE MY ACCOUNT FROM
THIS PROGRAM.
Signature:
Date:
(For Office Use Only): Employee Initials______ Date
Removed:____/____/____