Residential/Commercial Service Establishment Application

Service Location Information

Address of location at which service is requested Address Address 2

City/Town

State/Providence

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

Applicant Contact Info

Applicant's Phone Number

Applicant's Email

Applicant's Social Security Number

Applicant's Driver's License Number

Date of Birth

Applicant's Current Address is the same as Service Address? (or, if you have already moved into the address you are requesting service for please enter your prior address)

Yes No

Applicant's Current Address Address Address 2

City/Town

State/Providence

Zip/Postal Code

Applicant's Billing Address is the same as Service Address?

Yes No

Applicant's Billing Address Address Address 2

City/Town

State/Providence

Zip/Postal Code

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

Yes No

Water Related Emergencies For a water related emergency, whom should we contact?

Applicant Someone Else

Are you renting the property? Are you renting the property?

Yes No

Agreement of Terms - Initial please inital 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.

Signatures

Applicant Signature

Date of Applicant Signature