New Residential Service Application

Property Information

Own (Deed must be in your name)
Renter

Service Information

Previous Customer

First Name: Middle Initial: Last Name: DOB: DL# or ID#: DL# or ID# State issued: Passport#: Passport# Country issued: Service Address: Apartment/Suite: City: State: Zip Code: Home Phone #: Cell Phone #: Alternate Phone #: Email: Spouse Name:

Billing Information

Statement Type (Please select one): Paper Bill: E-mail:

Use Service Address

C/O First Name: Middle Initial: Last Name: Mailing Address: Apartment/Suite: City: State: Zip Code:

I certify, that to the best of my knowledge, the supplied information is true, accurate and complete.

Note: No work will commence until payment of the deposit, activation/administration fee and any additional fees are paid. Customers will be charged $13.00 per foot for the installation of a service line if it exceeds 100 feet in length. There is an activation/administrative fee of $50 per meter. Residential customers will have a minimum deposit of $125 per meter.

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