Previous Customer ( ) If so, when _________________________ New Customer ( )

Name __________________________________________ Phone#________________

Mailing address _________________________________________________________

Property Location _______________________________________________________

Applicant’s place of employment ___________________________________________

Employment address _________________________________ Phone#_____________

Name of spouse __________________________________________________________

Spouse’s place of employment______________________________________________

Spouse’s employment address __________________________ Phone# ____________

Rent ( ) Own ( ) If rent: Property owner’s name:___________________________

Property owner’s address ______________________________Phone#____________

I HEREBY AUTHORIZE SERVICE TO BE ESTABLISHED IN MY NAME AT THE ABOVE PROPERTY LOCATION AND AGREE TO PAY FOR SERVICE UNTIL DISCONTINUED BY MY REQUEST IN WRITING. I UNDERSTAND THAT THIS APPLICATION IS ACCEPTED SUBJECT TO THE AVAILABILITY OF SERVICE AT THIS LOCATION.

Applicant’s signature ____________________________________Date_____________

————————————————————————————————————
FOR OFFICE USE ONLY

Name ____________________________________________ Account No. __________

Deposit Amount _____________ Tap fee amount _____________

Meter Size _____________ Meter No. _____________

Date on ____________Date off _____________Customer request ( ) Termination ( )