TOMLINSON PUBLIC SERVICE DISTRICT

APPLICATION FOR SERVICE

Have you ever been a customer of Tomlinson or Grant PSD?  Yes_____ No_____

Name_____________________________________________________________

Phone#______________________ Email Address__________________________

Mailing Address_____________________________________________________

Property Location____________________________________________________

Applicant’s Place of Employment_______________________________________

Employment Address____________________________  Phone#______________

Name of Spouse________________________________   Phone#______________

Spouse’s Place of Employment_________________________________________

Spouse’s Employment Address_____________________ Phone#______________

List all residents over 18 years old:______________________________________

Own ( ) or Rent ( ) If rent: Landlord’s Name_______________________________

Landlord’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_______________________________________ Acct No._______________

Deposit _____ Ca  Ch #____  Tap Fee _____Ca  Ch#____  Date Paid___________

Meter Size____________ Meter No._____________

Date On______ Date Off______ Customer Request (  ) Termination (  )

TPSD OFFICE LOCATION 2830 SIXTH STREET NEW CUMBERLAND, WV 26047 (NO MAIL RECEPTACLE)

TPSD MAILING ADDRESS PO BOX 369 CHESTER WV 26034