I authorize the use of my cell phone (phone calls or SMS/text) and/or email by first or third party exclusively for the use of communication with me regarding my account status at any time. i agree that in the event my account becomes delinquent, I will pay processing fees and 1.5% interest on past due balances from the original due date, plus court costs and rasonable attorney's fees, with or without suit, incurred in collecting any past due balance, and a collection fee if my account is assigned to a collection agency.
Please enter full name.
Date of application:
Mailing Address:
City:
State:
Zip Code:
Telephone #:
E-mail Address:
Are you 18 or older:
Would you like this to be a joint account:
Secondary Account Holder Name:
Secondary Account Holder Phone:
Services Required:
Date to begin services:
Deposit Paid 150.00:
Service Address:
Is this a rental property:
Landlord name:
Landlord phone:
Set up preference verified by landlord on:
Do you own a dog or dogs:
Electronic Signature/Name /s/:
Date:
* required        
Account current name:
Are you moving:
If so what is the address of your new location:
Current home utility shut off date:  Calendar
New home utility turn on date:  Calendar
Home Phone:
Work Phone/Cell:
Billing Address:
City:
State:
Zip Code:
Email Address:
* required        
Current name on account:
New name:
Are you the owner of the property:
Service address:
Home Phone:
Work Phone/Cell:
Billing address:
City:
State:
Zip Code:
Email Address:
Change effective date:  Calendar
* required