UTILITY SERVICE(S) REQUEST FORM -- This form is used to establish utility services

DO NOT REPORT EMERGENCIES WITH THIS FORM!

DIAL 9-1-1 FOR ALL EMERGENCIES!

Customer's Full Name (First, Middle, & Last Name)  

Customer's Social Security Number  

Customer's Email Address  

Customer's Mailing Address (Include City, State Zip)

Day Time Phone Number  

Evening Phone Number  

Mobile Phone Number  

Customer's Employer's Name  

Customer's Employer's Mailing Address (Include City, State Zip)

Customer's Employer's Phone Number  

Street Address of Requested Services  

Start City Services [Water, Garbage Collection, & Sewer (if available)]?
Yes   No  

Date to Start City Services  

Will you need Natural Gas (if available)?
Yes   No  

Date to Start Natural Gas  

By electronically signing below in all caps, the customer agrees to be billed the necessary deposits to establish services. Generally, there is a $50.00 water deposit required and a $75.00 gas deposit required (if applicable). Deposits for businesses will be more.

NEW TAPS: If the City's water works, sewer system, or gas system has not already been "tapped" there will be additional charges for these services.

Prior to the establishment of any services, City Hall must receive a photocopy of the Customer's Indentification and a rent receipt (if a renter). Please fax the Identification and information to (229) 246-8879 to the attention of the BILLING COORDINATOR.

You must be present at the service location in order to have services connected.

Signature:(type in all capital letters to electronically sign)  

Date  

Specific Instructions or Comments