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OFFICE USE

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The OFFICE USE form is 1 page long and contains:

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  • 2 check-boxes
  • 41 other fields

Country of origin: OTHERS
File type: PDF

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OFFICE USE
Name:
Co-App:
Service Address:
Account No.:
Mailing Address:
Phone:
CITY OF MILTON-FREEWATER – UTILITY SERVICE APPLICATION
Applicant Information
Co-Applicant Information
Name
Name
Drivers License # & State
Drivers License # & State
Social Security number
Social Security number
Date of Birth
Date of Birth
Employer & Employer Phone
Employer and Employer Phone
email address
email address
Previous services with the city of Milton-Freewater?
Yes
No
If yes, when and under what name?
REFERENCES: (People who would know how to contact you in the event of an electrical/water problem)
1.
Name
Address
Relationship
Phone
2.
Name
Address
Relationship
Phone
I agree to abide by the terms and conditions set forth in the City’s ordinances, resolutions and policies regarding the use
of and payment for utility services. I understand that failure to pay when due may be cause for penalty charges or
disconnection. I affirm that the information given above is true and accurate to the best of my knowledge. I agree to
provide changes to any of the information provided above as soon as they take place.
Applicant’s signature
Date
Co-Applicants signature
Date
Deposit Information:
Amount Required:
$
Date Paid:
Amount Applied:
$
Date Applied:
FI or GC
Amount Refunded:
$
Date Refunded:
Ck #
Termination Date:
Remaining Balance: $
Remarks:
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OFFICE USE

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Completed 28 January 2021

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