Landlord Request for Utility Services

Landlord Request for Utility Services
Applicant Information
Date

Month Day Year
Date
Name *

First Name Last Name
Service Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Service Request Date *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com
Mailing Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Type of Business

Corporation Partnership Sole Proprietorship
President or Legal Representative
Federal Tax ID#
Driver's License or ID#
State
Date of Birth

Month Day Year
Date

Confidentiality
Please choose a 4 digit PIN to verify account information *
If there is not a recent GEUS pay history, the deposits will be based on credit history from Experian.
Acceptance will allow GEUS to check once annually. *

Accept Decline
Social Security Number
Required to pull personal credit history
Federal Tax ID#
Required to pull business credit score
**Failure to provide information could delay application process.

Previous Tenant Account
By signing this request in the space provided below, I hereby certify that:

1.     The tenant leasing/renting the Rental Premises from me has vacated the Rental Premises.

2.     This request is not being used by me in an effort to obtain payment of any rental that may be due and owing to me.

3.     This request is not being used by me for purposes of eviction of the tenant.

Should it be learned that the above references are not true, I agree that I will be required to come into the GEUS Consumer Service Offices and sign an affidavit, under penalty of perjury, for any Landlord directed request for disconnection of a tenant’s property and that any violation of that affidavit will be forwarded to the appropriate law enforcement agency for action, up to and including prosecution.

I hereby acknowledge, agree and aver that GEUS is not my agent in any form related to disconnection of any service. I hereby agree to indemnify and hold GEUS harmless should any action ever be brought against GEUS as my agent related to my misuse of GEUS for any purpose, including as a tool to extract rental payments or eviction. Such indemnification includes and an all attorney’s fees GEUS incurs in defending itself from any action related to this request.
Agreement
The Applicant, whose signature appears below, applies to GEUS for some or all of the following services: Electric, Water, Sewer, Garbage, Cable TV, Internet and other services incident thereto, to be supplied at the address herein described, and upon request, at any other local address to which Applicant may move.

The Applicant agrees to pay for said services as bills are rendered therefore, in accordance with the rates, rules and regulations as provided in the City Charter or by City Ordinances as now existing or as may be enacted and in effect at the time of delivery, regardless of who the consumer might be.

The Applicant further agrees to release and discharge said GEUS or the City of Greenville from a liability for damages suffered

(1) by reason of electric or water currently furnished to the premises, or

(2) by reason of interruption, discontinuance or disconnection of service hereunder from any cause other than negligence by GEUS or the City of Greenville or

(3) by reason of the condition, maintenance, location, or existence of any of the facilities, fixtures or systems located on or adjoining the property supplied and by which services are furnished and delivered.

Service requests for disconnections will be processed within 2 business days.
Applicant agrees to follow all current or as amended policies and procedures established in the Greenville City Ordinances and GEUS Service Policy. Such policies and procedures can be found on the links provided below.

http://www.geus.org/175/Service-Policy-Manual-PDF

http://z2.franklinlegal.net/franklin/Z2Browser2.html?showset=greenvilleset
Landlord Signature *

First Name Last Name
Date *

Month Day Year
Date
Landlord Signature *

Clear
Should be Empty:

Landlord Request for Utility Services

Applicant Information

Confidentiality

Previous Tenant Account

Agreement