RESIDENTIAL APPLICATION FOR UTILITY SERVICE
Completed Applications must be received at least 1 business day prior to your service start date. A service order charge of $25.00 will appear on your first statement.
Required Documentation Needed to Complete This Application
Copy of Government Issued photo ID for all individuals 18 years of age and older
Lease agreement will be required for all individuals who rent (or rent to own) their residence
Deposit or qualifying Letter of Prior Payment history from your previous electric provider
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Start Date
*
-
Month
-
Day
Year
Date
Will You Be Occupying The Address?
*
Yes
No
Are You The
*
Owner
Renter
Account Holder Information:
Everyone living at the above service address 18 years of age and older is required to be on this application.
Name
*
First Name
Last Name
Previous Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Government Issued photo ID Type
*
Please Select
Drivers License
State ID
Military ID
Passport
Government Issued photo ID Number
*
Co-Account Holder(s) Information:
Others living at this service address 18 yrs of age and older are required to provide a valid ID, their information and sign this form.
Name
First Name
Last Name
Relationship to Primary
Primary Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Government Issued photo ID Type
Please Select
Drivers License
State ID
Military ID
Passport
Government Issued photo ID Number
Previous Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Co-Account Holder(s) Information:
Others living at this service address 18 yrs of age and older are required to provide a valid ID, their information and sign this form.
Name
First Name
Last Name
Relationship to Primary
Primary Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Government Issued photo ID Type
Please Select
Drivers License
State ID
Military ID
Passport
Government Issued photo ID Number
Previous Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
In case of an emergency who would you like for us to contact? Must have full address and phone number of someone not living at this service address.
Name
First Name
Last Name
Relationship to Primary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Utility Customer Service Programs
Details can be found on our website www.edmondok.com
EMSACare: Emergency ambulance service (EMSA). The program cost is $3.00 per month and billed on your utility statement each month. This program is for all occupants. Everyone over the age of 18 must be on the utility account. Changes to enrollment may be made each year in October. Would you like to enroll at this time?
*
Yes
No
Solid Waste/ Trash Pick-up: We supply one trash cart, and one recycle cart for the monthly base rate charge. Extra trash carts may be requested for an additional monthly charge of $7.00 each. Trash pick-up is weekly, recycle pick-up is every other week. How many additional Solid Waste trash carts would you like?
*
Please Select
0
1
2
3
4
Auto Draft: By selecting yes, I authorize the City of Edmond to begin monthly recurring bank drafts from my checking account for payment of my utility bills. I understand the City of Edmond reserves the right to end my participation in the Automatic Bank Draft program.
*
Yes (voided Check Required)
No
Kidney Dialysis
If at ANY time a member of household starts in home Kidney Dialysis please notify our office immediately.
Is any resident in this home on Kidney Dialysis?
*
Yes
No
If there is any resident in this home on Kidney Dialysis, please enter their name.
First Name
Last Name
Are the Kidney Dialysis treatments performed at home?
*
Yes
No
Copy of Government Issued photo ID for all individuals 18 years of age and older
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Lease agreement for individuals who rent (or rent to own) their residence
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Qualifying Letter of Prior Payment History from your previous electric provider (a deposit may be required without a Qualifying Letter of Prior Payment History)
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Agreement of Understanding
The Primary and Joint Owners of this account agree to pay adopted rates set forth by the City Council for the City of Edmond/ Edmond Public Works Authority and follow regulations governing said services. This application becomes a financial contract upon the establishment of utility service. I understand if on a Letter of Prior Payment History and no longer meet the requirements I will be billed a deposit.
Account Holders’ Signature:
*
Co-Account Holders’ Signature:
Co-Account Holders’ Signature:
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Submit
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