Application to Start Owner Occupied Services Application to Start Owner Occupied Services Please complete and review the Applicant's Statement and Acknowledgements. To finalize the service change, the party disconnecting MUST notify City Hall. Applicant(s) Information Start Service(s) Date: * Today's Date: * Account Name: * Responsible Party(ies) Service Address: * Service Address: Service Address: Service Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone Number: * Secondary Phone Number: Email: * Type of Service(s) Requested: * Electric Service Water Service Electric & Water Services Mailing address if different from service address: Mailing address if different from service address: Mailing address if different from service address: Mailing address if different from service address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Have you ever had, or do you currently have Breese utilities? * Yes No If yes, what was the address? If yes, what was the address? If yes, what was the address? If yes, what was the address? City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Applicant's Statement and Acknowledgements By requesting the City of Breese to furnish utility service(s) at the above address, you agree to pay all bills on or before the 25th of each month and to be responsible for all utilities consumed at the above address. You further agree that if the utility bill is not paid by the 10th of the month following the due date, the city is authorized to discontinue such service(s) with a final notice. When a deposit is required, you further agree that service(s) will not be changed to your name until the deposit and all required documents are completed and turned into the City. The City of Breese reserves the right to require a signed application for utility service(s) to be submitted in person along with a form of ID. Customer will be subject to current rates, rules and regulations as approved by the City of Breese. You must notify the city when you vacate to end service(s) at the address you are vacating. Otherwise, you could be liable for any charges incurred after you have moved. Application for service(s) shall be made in the legal name of the party obligated to pay for service(s). Terms of Acceptance * I understand that checking this box constitutes a legal signature confirming I acknowledge and agree to the above Statement and Acknowledgements. Electronic Signature: * Electronic Signature: First Name First Name Last Name Last Name Date: * Submit If you are human, leave this field blank. Skip back to main navigation
