City of Social Circle
Application for Utility Services
To apply for Utility Services, the following items must be submitted:
1. U.S. Driver’s License, Government Issued ID, Passport or Green Card.
2. Lease agreement for either Rental property or Lease or Own Property.
Please print information clearly
For office use only:
Today’s Date:
Representative:
Check if document has been scanned
Date Service Requested: Account No:
Applicant’s Name:
First M.I. Last
Service Address:
Street Address City ZIP
Mailing Address:
Street Address
City State ZIP
Home Phone #: Work Phone #: Cell Phone #:
Customer Email: Receive Email Bills Receive Text/Phone notifications
Drivers License #: State: Date of Birth (MM/DD/YY):
Nearest Relative: Phone #:
Applicant’s Employer:
Employer’s Address: Employer’s Phone:
Spouse/Roommate:
Employer:
Employer’s Address: Employer’s Phone:
Previous Service Location:
Water Tap Fee: Water CRC Fee: Sewer Tap Fee: Gas Tap Fee: Admin Fee:
Water Deposit Amount: Gas Deposit Amount:
Water Reading: Gas Reading:
Water Ref Customer: Check No: Gas Ref Customer: Check No:
Water Ref City: Check No: Gas Ref City: Check No:
Applicant hereby authorizes the City of Social Circle (the “City”) to use collection agencies to collect past due balances. Applicant agrees to act as
guarantor for any and all payments due and owing the City on this account. As guarantor, applicant further agrees to pay all costs of past due
accounts, including postage, second notices, collection fees, and also reasonable attorney’s fees and court costs if through legal action or an
attorney. Applicant agrees that meters used by the City to measure utility usage can be read incorrectly or can malfunction resulting in a bill to
the Applicant that understates the actual usage. Applicant hereby agrees that the normal statute of limitation, the right to review bills and correct
the errors caused by the operation or reading of a meter shall extend for a period of six years.
I hereby certify that the foregoing information is true and accurate to the best of my knowledge and belief.
Applicant Signature: Date:
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