Have you ever been a customer of Tomlinson or Grant PSD?          Yes____ No____

Name __________________________________________

Phone#________________ Email Adress_____________________________________

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# ____________

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 ____________________________________________ Account No. __________

Deposit Amount _______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