FA-916_17217_CA_WL_20100525_Johnston County water line connection application

Johnston County Department of Public Utilities An Application for Service is required to be completed prior to service being connected. Johnston County Public Utilities requires at least one business day’s notice prior to scheduling the connection. The security deposit must be satisfied at the time of application. The deposit may be waived if a letter of credit from your previous utility company indicating no late payments for the most recent 12-month period is submitted along with the properly completed application. ONLINE APPLICATION: Complete the on-line application and fax the form to [phone]. If during normal business hours, a Customer Service Representative will contact you within two (2) hours to obtain additional information and for payment of all charges. Make sure an accurate contact name and phone number is included. You will need the following information to establish a new account: • Valid Name of Account holder. Credit is being extended only to the name(s) on the established account • Social Security Number • Valid Driver’s License or other Government-Issued Photo Identification • Physical Address of the Property-where the property is located • Billing Address –where the bill should be mailed • Telephone Number • Rental Receipt or lease agreement--(If not the property owner) • Employer’s Name, address and telephone number • Payment of Fees: o Application Fee o Deposit or a letter of credit from your previous utility company indicating excellent payment history for the most recent 12-month period o Other Fees as required Disclosure of Social Security number: Johnston County is authorized to collect this information due to extending credit for services, identify customers and collecting of debts owed to Johnston County. Without this information additional deposit or other pertinent information may be required to establish service. In compliance with the Federal Trade Commission’s Fair and Accurate Credit Transaction Act of 2003, and the Identity Protection Act of 2005 Johnston County is required to identify its customers. Johnston County will be verifying customer information using the Social Security number through a credit reporting agency.
P.O. Box 2234
309 East Market StreetSmithfield, NC 27577 Fax: [phone]
Customer: #_________________________
Have you been a previous customer of Johnston County Public Utilities? __________ YES __________ NO
ACCOUNT NUMBER _________________________
PARCEL NUMBER ______________________________
RESIDENTIAL ________ BUILDER ________ DEVELOPER ________ WELL DISCONNECT ________ READY LETTER DATE ____________________
WATER TAP _______________ SIZE _______________ SEWER TAP _______________ SIZE _______________
FEES DUE
APPLICATION FEE
DEPOSIT
ASSESSMENT FEE
TAP FEE
METER FEE
OTHER __________
TOTAL DUE
_______________________
CUSTOMER SERVICE REPRESENTATIVE
STATE - NUMBER
APPLICANT CO-APPLICANT
Phone: [phone]
PHONE # (TEL)
APPLICATION FOR UTILITY SERVICES
WATER FEES WASTEWATER FEES
PREVIOUS CUSTOMER NAME ______________________________________________________________________________________________________
FOR OFFICE USE ONLY
DATE:CUSTOMER SIGNATURE:
BOOK/ROUTE ___________
PAYMENT
MAILING ADDRESS ______________________________________________________________________________________________________________________
OPTIONAL CELL PHONE #____________________________________CITY _________________________________STATE __________ZIP _______________
If yes, what name and address _______________________________________________________________________________________________________________
I, the undersigned, hereby make application for water and sewer service and certify that all the above information is correct. I agree to abide by all rules and regulations of the Johnston County
Department of Public Utilities. I understand and agree to pay monthly charges once the meter has been placed in service. Property owners will be responsible for a monthly bill regardless of whether
water and/or sewer is used, until the property is sold or rented.
SOCIAL SECURITY #
DATE OF BIRTH
EMPLOYER NAME EMPLOYER NAME
STATE - NUMBER
DATE OF BIRTHDRIVERS LICENSE # or STATE ID CARD DRIVERS LICENSE # or STATE ID CARD
PHONE # (TEL)EMPLOYER ADDRESS PHONE # (TEL)
OWNER ______________________________ (If new owner, closing date of property) ___________________________________________________________________
E-MAIL ADDRESS
SERVICE ADDRESS _______________________________________________________________________________________________ CITY __________________
FORM MUST BE COMPLETED IN FULL BEFORE SERVICE IS MADE AVAILABLE
EMPLOYER ADDRESS
RENTER ______________________________(If renting, property owner & phone #) ____________________________________________________________________
SUBDIVISION _____________________________________________________________________________________________________ LOT __________________
MOBILE HOME PARK ____________________________________________________________________________________________LOT __________________
NAME (FIRST, LAST) NAME (FIRST, LAST)
SOCIAL SECURITY # OR TIN PHONE # (TEL)
JOHNSTON COUNTY DEPARTMENT OF PUBLIC UTILITIES
TOTAL PAID $___________
$___________________________
$___________________________
$_____________________________
$______________________________
$_____________________________
RECEIPT # ______________
CASH ___________________
CHECK _________________
CREDIT CARD __________
$_______________________
$_________________
IDENTIFICATION IS REQUIRED
WATER DISTRICT _______________CYCLE _______________
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
$____________________________
$__________________________
START DATE OF SERVICES____________________________________________MOVE IN DATE ___________________________________________________