Utility Service(s) Request

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Utility Service(s) Request

This form is used to establish utility services.

Do not report emergencies with this form!
Dial 9-1-1 for all emergencies!

* Denotes a required field

Please Do Not Complete The Following Field

Customer Information

First Name*

Middle Name

Last Name*

Social Security Number*

Mailing Address (Include City, State & ZIP)*

Daytime Telephone

Phone -- Extension

Evening Telephone

Phone -- Extension

Mobile Telephone

Phone -- Extension

Customer's Employer

Employer's Name

Employer's Mailing Address (Include City, State & ZIP)

Employer's Telephone

Phone -- Extension

Requested Services

Street Address of Requested Services*

Do you want to start City Services (Water, Garbage Collection & Sewer), if available?*

Yes No

If yes, when would you like to start City Services?

MonthDay Year,

Will you need Natural Gas, if available?*

Yes No

If yes, when would you like to start Natural Gas?

MonthDay Year,

By electronically signing below in all caps, the customer agrees to be billed the necessary deposits to establish services. Generally, there is a $150.00 water deposit required and a $150.00 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 Identification and a rent receipt (if a renter). Please fax the Identification and information to (229) 246-7311 to the attention of the BILLING COORDINATOR.
You must be present at the service location in order to have services connected.

*Please type in all capital letters to electronically sign.

Signature*

Date*

MonthDay Year,

Specific Instructions/Comments

Security Measure

City of Bainbridge