APPLICATION FOR UTILITY SERVICE
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