Utility Billing Application
1
Homeowners please submit this application
We accept cash, check, & debit
along with a copy of HUD and photo id.
Applications by mail, fax, or email with required
Renters are required to pay a $150.00 Deposit
documentation, drivers license, and SS card
($75.00 for sanitation only accounts) plus
must be submitted to process application.
submit a copy of lease agreement and photo id.
City of Pooler
100 US HWY 80 SW
A $75 non-refundable sanitation maintenance
Pooler, GA 31322
fee will be billed to all new customers.
Ph. (912) 748-4800
Fax (912)748-6777
utilitybilling@pooler-ga.gov
Apartment/Suite City State Zip
Month Day Year
Place of Employment_____________________________
I would like to receive bill by: (please check)
MAIL
EBILL (email)
Email (Ebill) address ________________________________________
___________________________________________ __________________________ ____________________________ _______________________________
Email address ________________________________________
Co-Applicant Name_________________________________________________
Transfer/Previous Address Information
Drivers License _______________________________________
Drivers License _______________________________________
Applicant/Owner Information
ACCT_________________________________________________________________
SETTLEMENT PAPERS__________________________________________________
DEPOSIT RECEIPT #_____________________________________________________
COPY OF C.O.________________________________________________________
Own __________ Settlement Statement Required
CHECK #____________________________________________________________
Birth date _________/__________/___________
DATE ENTERED _________/__________/___________
BY:_________________________________________________________________
Name________________________________________________________
Birth date _________/__________/___________
Today's Date _________/__________/___________
Rent _________ Requires $150 deposit & copy of lease
Mailing Address (If different from service address)__________________________________________________________________________________
Date to Start Service _________/__________/___________
Service Address_____________________________________________________________________________________________________________
"The following information is required by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants
seeking to participate in the program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in
Place of Employment_____________________________
If Yes, Previous Address_______________________________________________________________________________________________________
(If transferring account, please fill out disconnection form)
Have you ever had service with the City of Pooler before? Yes______ No_______
evaluation of your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national