Utility Service Application

Purpose: This document is used by residents to request the connection or disconnection of utility services such as water, electricity, or gas. It helps utility providers to process service requests efficiently and maintain accurate service records.

Applicant Information

Full Name: {fullName}

Address: {address}

Phone Number: {phoneNumber}

Email: {email}

Date of Application: {applicationDate}

Service Request Details

Type of Request: {serviceType}

Utility Type: {utilityType}

Service Address: {serviceAddress}

Preferred Start/End Date: {preferredDate}

Account Number (if applicable): {accountNumber}

Additional Occupants

{#occupants}

• Name: {name}, Relationship: {relationship}

{/occupants}

Documents Submitted

{#documents}

• {documentName}

{/documents}

Billing Information

Billing Name: {billingName}

Billing Address: {billingAddress}

Payment Method: {paymentMethod}

Special Instructions

{specialInstructions}

Declaration

I, {fullName}, hereby request the above utility service action and confirm that all provided information is accurate and complete to the best of my knowledge.

{#hasTermsAcknowledged}

The applicant has acknowledged the terms and conditions.

{/hasTermsAcknowledged}

{^hasTermsAcknowledged}

The applicant has NOT acknowledged the terms and conditions.

{/hasTermsAcknowledged}

Official Use Only