APPLICATION FOR UTILITY SERVICE

FOR RENTERS

 

NAME: _________________________________________________________________

SERVICE ADDRESS: ___________________________________________________________________

BILLING ADDRESS (if different from service address): ________________________________________

HOME TELEPHONE NUMBER: __________________________________________________________

WORK TELEPHONE NUMBER: __________________________________________________________

I hereby apply for ______gas and/or ______garbage services for the service address listed above pursuant to the following conditions:

I agree to pay a minimum deposit of the highest gas bill for that property in the past twelve months and connection fees prior to service connection for gas service.

I agree to pay all bills rendered by Lenox Gas System for services provided beginning

______________________, 20____ to the date service is discontinued.

I agree to give notice to Lenox Gas System of my intent to discontinue service.

I hereby verify that I have no outstanding bills with the Lenox Gas System under my current

name or any other name I have used in the past, or under a current or former spouse’s name.

 

 

 

_____________________________________ _______________________________________

Lenox Gas System Representative Renters Signature

 

 

 

_____________________________________

Date