WMUC, TSR Form, Revised 4/13
30-Day Temporary Service Request Form
In accordance with WMUC Policy 7.14 Temporary Service Policy: Customer needing service for
clean up, repairs, or building is allowed service if customer has active/current account with us;
otherwise, the requestor is required to set up account including deposit. There will be a $20.00
service fee applied to the first billing. If you do not have an active account with us, the deposit
and service fee will be $120.00 paid before service will be established.
Street Address: ________________________________________________________________
TEMPORARY SERVICE ADDRESS (PLEASE PRINT)
CUSTOMER INFORMATION (PLEASE PRINT)
Name _____________________________________________________________________
Billing Address: _____________________________________________________________
City: _____________________________State; _______________ Zip Code: ___________
Phone: ____________________________ Email: _________________________________
SSN/Tax ID#_________________________________________________________________
Turn On Date:_______________________ Turn Off Date:__________________________
Received By: __________________ Date: _____________
Completed By: _______________ _ Date: ____________
New AVO#: _____________________________ Disconnect AVO#:__________________________
I, the undersigned, agree to pay a $20 service charge plus all other charges accrued during
the 30-day period of temporary service. I understand temporary service is only granted for a
30-day period.
Signature: _________________________________________________ Date: ______________
