Residential Service Application

Residential Service Application
Applicant Information
Full Name

First NameMiddle NameLast Name
Social Security No
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Home
Phone Number
Mobile
Phone Number
Work
Phone Number
Work Ext
Extension
Email
jdoe@ecarthage.com
Emergency Contact Info
Emergency Contact

First NameLast Name
Phone
Upload a scan or photo of applicant ID

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Do you want to add a Co-Applicant?

Co-Applicant Information
Co-Applicant Name

First NameMiddle NameLast Name
Social Security No
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Home
Phone Number
Mobile
Phone Number
Work
Phone Number
Work Ext
Extension
Email
jdoe@ecarthage.com
Upload a scan or photo of co-applicant ID

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Would like like to list additional applicants on the account?

Property Information
Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ownership
Landlord's name
Lease agreement or proof of ownership

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Please provide a photo or scan or your lease agreement or proof of ownership of the property. Cancelof
Mailing Address
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Connection Request
What services would you like connected?
Which fiber internet package would you like?
Have you already paid a utility deposit?
Deposit Amount Paid?
Requested Connection Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your application must be submitted by noon for same day service. Service will be connected between 8 am – 5 pm Monday – Friday
Do you have any comments relating to the connection?

Contract Signatures
Any and all services provided shall be subject to the regulations, policies, and rates of CWEP. I understand that I am responsible for the utility billing at the above property from the date of requested connect (or transfer) until I personally order the service off. This information serves as an contract for utility service with Carthage Water & Electric Plant.
Applicant
Co-Applicant
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Applicant Information