City of Louisburg
913-837-5371 913-837-5374 (Fax)
215 S. Broadway
LOUISBURG, KS 66053
APPLICATION FOR GAS AND / OR WATER SERVICE
Today’s Date_____________ Deposit Pymt $__________Paid_______
(Renter’s only)
Date you would like service to begin:_____/______/______
Do you want :
gas on______ off______initial______.
Do you want : water on______ off______initial______.
Name applying for service________________________________________________
Address for service ______________________________________________________
Mailing Address ________________________________________________________
(If different from above)
E-mail address___________________________________ I am interested in e-billing_______
Telephone # Hm ______-______-______ Cell ______-______-______Work______-______-______
SSN# ________-______-________ DL# _________________DOB_____/_____/_____
(Required)
______Own (must have copy of ownership papers)
______ Rent (must have deposit $100.00 Gas - $50.00 Water)
Landlord’s Information:
Name _____________________________ Address ___________________________________________
This is a legal binding document. By signing this you agree to assume financial responsibility for all accrued
charges. You must provide notification of change of residence and a forwarding address. If our office is not
notified, you are responsible for all accumulating charges until the account is closed. By signing below you
acknowledge the agreement between you (resident) and the City of Louisburg. Collection Bureau of Kansas
will be notified of all past due debt and will pursue collections on the behalf of the City of Louisburg.
Signature _________________________________________ Date_______________________
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signature
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