TOWN OF WAYNESVILLE

RESIDENTIAL APPLICATION FOR UTILITY SERVICE

APPLICATION DATE _____________________ DATE TO CONNECT _____________________

NAME _____________________________________________ SS #_____________________

CO-APPLICANT _____________________________________SS# ______________________

SERVICE ADDRESS ___________________________________________________________

MAILING ADDRESS ____________________________________________________________

TELEPHONE # (HOME) ______________________ WORK _____________________________

OWN ___ RENT ___ MOBILE HOME ___ IS MOBILE HOME ON RENTED LOT? ______________

IF RENTING, NAME OF PROPERTY OWNER _________________________________________

NAME OF PREVIOUS OCCUPANT _________________________________________________

TYPE OF HEAT? ELECTRIC/BASEBOARD ______ GAS ______ OIL ______ WOOD ______

PLACE OF EMPLOYMENT ________________________________________________________

CO-APPLICANT _________________________________________________________________

HAVE YOU OR CO-APPLICANT HAD UTILITY SERVICE WITH THE TOWN BEFORE?

YES____ NO____ IF SO, WHEN ___________________________________________________

MOVING FROM WHERE? ________________________________________________________

THE UNDERSIGNED AGREES TO THE FOLLOWING CONDITIONS FOR UTILITIES REQUESTED:

1) Utilities are billed monthly and are payable within ten (10) days from bill date.
2) Bills are past due after 25 days. A late penalty of 1% is added and a delinquent notice is mailed to customer.
3) Service will be disconnected if payment is not received by due date of delinquent notice.
4) Any tampering with meters or related equipment is a violation of the law and is subject to prosecution
    and service termination.
5) Deposits will be applied to final bills and the balance, if any, will be refunded.
6) There will be a $20 non-refundable connect charge listed on your first bill as other charges.
7) Applications for service at rented units must have a lease or rent receipt attached.
8) Once utility bills and delinquent notices are placed in the United States Postal box outside our office,
    we are not responsible if not received by the customer.

Signature of Applicant ________________________________________

Driver License ______________________________________________

Signature of Co-Applicant _____________________________________

Driver License ______________________________________________