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