Fillable RESIDENTIAL UTILITY SERVICE APPLICATION (Town of Bedford)

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RESIDENTIAL UTILITY SERVICE APPLICATION (Town of Bedford)

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U.S.A. forms for Town of Bedford

BROWSE TOWN OF BEDFORD (VA) FORMS

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215 E Main ST
Bedford, VA 24523
Utility Billing Office 540-587-6047 Fax 540-587-6143 E-Mail billing@bedfordva.gov
CALL BILLING OFFICE FOR Deposit Required 540-587-6047 Option 1
RESIDENTIAL UTILITY SERVICE APPLICATION
DATE OF APPLICATION____________________DATE SERVICE DESIRED__________________
DEPOSIT DATE____________________DEPOSIT AMOUNT_____________________________
DATE OF BIRTH______________________ SOCIAL SECURITY #__________________________
NAME_______________________________________________________________________
SPOUSE NAME________________________________________________________________
SERVICE ADDRESS______________________________________________________________
MAILING ADDRESS IF DIFFERENT THAN SERVICE ADDRESS
_____________________________________________________________________________
HOME OR CELL PHONE #_________________________WORK#_________________________
E-Mail______________________________________________________
RESIDENCE: OWN_____ RENT_____LANDLORD_____________________________________
PREVIOUS SERVICE ADDRESS_____________________________________________________
ACCOUNT # _________________________CUTOFF DATE______________________________
I UNDERSTAND THAT THIS APPLICATION FOR UTILITY SERVICE WITH THE TOWN OF BEDFORD WILL ESTABLISH AN
ACCOUNT IN MY NAME AND THAT I WILL BE RESPONSIBLE FOR ALL CHARGES THAT ARE INCURRED ON THIS
ACCOUNT. I ALSO AGREE TO ABIDE BY THE TERMS AND CONDITIONS OF THE TOWN ELECTRIC TARIFF AND
OTHER ORDINANCES GOVERNING THE UTILTIY SERVICES PROVIDED BY THE TOWN OF BEDFORD AS AMENDED
FROM TIME TO TIME BY THE TOWN COUNCIL.
SIGNATURE_________________________________DATE___________
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RESIDENTIAL UTILITY SERVICE APPLICATION (Town of Bedford)

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Completed 18 January 2021

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