April 2018
TOWN OF CLAYTON
Engineering & Inspections
111 E. Second St., P.O. Box 879
Clayton, NC 27528
Phone: 919-553-5002
Fax: 919-553-1720
Business Name: __________________________________________________________________________
Contact (during business hours) _____________________________________________________________
Service Address __________________________________________________________________________
Phone _______________________________________ Fax ______________________________________
Mailing Address __________________________________________________________________________
Emergency Contact (after hours) _____________________________________________________________
Federal Tax ID Number ____________________________________________________________________
Amount of Deposit $ __________________________ Connect Fee $ __________________________
If rental property, who is the owner/landlord? _________________________________________________
Date of service is to be turned on _____________________________________________________________
I certify that I am authorized to sign for the above business; that the above information is accurate, and that
_________________________ will be responsible for payments of entire bill upon termination of service. I
have had an opportunity to review a copy of the Town of Clayton cut off policy and am subject to the Town’s
Utility Policy as currently in effect. The account will be subject to immediate disconnection without further
notice if deposit and connect fee payment is returned for insufficient funds.
Date: __________________ Authorized Signature: _____________________________________________
Town of Clayton Employee: _________________________________________________________________
APPLICATION FOR BUSINESS SERVICES
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