Fillable County of Brunswick Public Utilities Department P. O. (Brunswick County)

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County of Brunswick Public Utilities Department P. O. (Brunswick County)

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File type: PDF

U.S.A. forms for Brunswick County

BROWSE BRUNSWICK COUNTY (NC) FORMS

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County of Brunswick
Public Utilities Department
P. O. Box 469
Bolivia, NC 28422
APPLICATION FOR SERVICE
Section (A) Please Fill Out
Street Name & Number (Meter Location)
Lot Number
Subdivision Name
Tax ID or Parcel Number
Lot Vacant? Yes No
Non-Residential? Yes No
Billing Address:
Name: ______________________________________
______________________________________
Address: _____________________________________
City: _____________________________________
State: _____________________________________
Zip : _______________
Phone Numbers:
WORK: ( )
HOME: ( )
CELL: ( )
(if Tenant)
OWNER: ( )
Date of Transfer: _______________ DOB: ___ / ___ / _______
Email Address: _________________________________________________
Last (4) digits SS#: ____ ____ ____ ____ (The last four digits of your Social Security
Number are requested for billing and collection purposes)
Driver’s License Number: _________________________ State Issued: __________
Check One:
Owner
Tenant
Builder
Section (B) Office Use Only
Account Number: _______________ Customer Number: _______________
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County of Brunswick Public Utilities Department P. O. (Brunswick County)

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Completed 5 August 2020

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