Residential/Commercial Service Establishment Application

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Service Location Information

Address of location at which service is requested

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Date occupancy began or is anticipated to begin

Applicant Information

I am a...

Property Owner

Tenant

Name of Applicant

First

Last

Suffix

Driver's License Number

Date of Birth

Applicant's Billing Address (if different from service address)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Applicant's Phone Number

Applicant's Email

Do you have a Co-Applicant (second name that will appear on bill)?

Yes

Co-Applicant Information (if a second name will appear on the bill)

Name of Co-Applicant

First

Last

Suffix

Co-Applicant's Billing Address (if different from service address)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Co-Applicant's Phone Number

Co-Applicant's Email

Are you renting the property?

Yes

Landlord Contact Information

Name

Company

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Agreement of Terms - Initial

Please initial all fields below.

Falsification of information on this application may be case for termination of utility service.

Utility services may be disconnected for failure to pay your account balance by the designated date or they may be certified as a lien against the property.

Wooster City Services takes customer identity information seriously and has adopted and implemented "Red Flag Rules" in an effort to protect its customers. These rules do not prohibit Wooster City Services from disclosing forwarding addresses, phone numbers of property owners or tenants nor does it prohibit Wooster City Services from giving out payment history of its customers.

Receiving a new bill that is not due until the 23rd of the month does not reset the due date for unpaid charges from prior months. Those charges are still past due and subject to service disconnection. Receiving a new bill with a due date of the 23rd does not prevent service disconnection for past due charges.

If you anticipate ever renting the property to a third party, or otherwise anticipate any changes in occupancy, you have a continuing obligation to advise the Utility Department of any changes in the occupancy of the premises, and the identity and mailing address of new tenants and/or occupants. By initialing, you are acknowledging that all billings for services are primarily the responsibility of the property owner even if bills are being sent to tenants in their name.

Please provide the address you currently reside at or if you have already moved into the address you are requesting service for please enter your prior address

Address

City/Town

State/Province

ZIP/Postal Code

By signing and initialing this application, you acknowledge you have read the application and agree to abide by the terms listed above.

Signature of Applicant

Applicant Signature Date

Signature of Co-Applicant

Co-Applicant Signature Date