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_____________
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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