Homeowner Application for Utility Service

Date

Phone No.

Account No.

Name

Email Address

SS#

DL#

Co-Applicant

SS#

DL#

Service Address

Mailing Address

Application For:

ELECTRIC

GAS

WATER

SEWER

SANITATION

Immediate Relative:

Name

Phonenumber

Personal Reference:

Name

Phonenumber

Place of Employment & Address

Co-Applicant Employment & Address

I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR THE UTILITY BILLING. I FURTHER UNDERSTAND THAT IF MY ACCOUNT BECOMES DELINQUENT, I WILL BE RESPONSIBLE FOR ANY EXPENSES INCURRED IN COLLECTING MY ACCOUNT. SPECIFICALLY, THERE MAY BE LEGAL FEES OR EXPENSES CHARGED BY AN INDEPENDENT COLLECTING AGENCY OF AN ADDITIONAL 25% WHICH I SHALL BE LIABLE FOR.

ALL METERS, SERVICE CONNECTIONS, OUTDOOR LIGHTS, AND OTHER EQUIPMENT FURNISHED BY THE DISTRIBUTOR ARE, AND SHALL REMAIN THE PROPERTY OF THE DISTRIBUTOR. THE CUSTOMER SHALL PROVIDE SPACE FOR AFORESAID EQUIPMENT AND DEVICES AND SHALL EXERCISE PROPER CARE TO PROTECT ALL PROPERTY OF THE DISTRIBUTOR ON HIS (THE CUSTOMER’S) PREMISSES. IN THE EVENT OF LOSS OR DAMAGE TO DISTRIBUTOR’S PROPERTY ARISING FROM NEGLIGENCE ON THE PART OF THE CUSTOMER IN CARING FOR SAME, THE COST OF NECESSARY REPAIRS OR REPLACEMENTS SHALL BE PAID BY THE CUSTOMER. ACTION OF WILLFUL AND MALICIOUS DESTRUCTION OF DISTRIBUTOR’S PROPERTY SHALL RESULT IN LEGAL PROSECUTION OF THOSE INDIVIDUALS RESPONSIBLE FOR SUCH ACTS, AND FULL MONETARY RESTITUTION SHALL BE MADE FOR ANY DAMAGES. RESPONSIBILITY FOR OFFENSES PERPETRATED BY MINORS SHALL REVERT TO MINOR’S PARENTS OR LEGAL GUARDIANS.

I ALSO AGREE TO PROVIDE SAFE, AMPLE ACCESS AT ALL TIMES TO ALL UTILITY METERS AND EQUIPMENT ON MY PROPERTY BY CONFINING OR RESTRAINING ANIMALS A SAFE DISTANCE AWAY, BY CUTTING BUSHES AND UNDERGROWTH, AND BY KEEPING MY PREMISES CLEAN, SO THAT THERE ARE NO OBSTRUCTIONS TO THE AFORESAID UTILITY METERING OR EQUIPMENT. NOTE: A $25.00 CONNECTION FEE WILL BE ADDED TO THE INITIAL BILL ONLY.

Digital Signature of Applicant

Digital Signature of Co-Applicant