Application and Contract for Utility Services

Application and Contract for Utility Services
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Requesting to Start Services (Monday-Friday excluding Holidays) *Start date must be within 5 business days of the day your are completing your application**

MonthDayYear
Date
Please Select*

I rent this propertyI own this property
If renting the property please provide a copy of the Lease Agreement.

Cancelof
If you own the property please provide a copy of the closing disclosure, settlement statement or deed.

Cancelof
Applicant Information
Applicant Name*

First NameMiddle NameLast Name
Applicant Social Security Number*
Applicant Date of Birth*

MonthDayYear
Date
Applicant Driver's License State*
Applicant Driver's License Number*
Driver's License Upload*

Cancelof
Applicant Primary Phone*
Please enter a valid phone number.
Applicant Alternate Phone
Please enter a valid phone number.
Applicant Email Address (You will automatically be enrolled in our paperless billing)*
example@example.com
Applicant Employer*
Applicant Employer Phone*
Please enter a valid phone number.
Is there a co-applicant?*

YesNo
Co-Applicant Information
Co-Applicant Name

First NameMiddle NameLast Name
Co-Applicant Social Security Number
Co-Applicant Date of Birth

MonthDayYear
Date
Co-Applicant Driver's License State
Co-Applicant Driver's License Number
Co-Applicant Driver's License Upload

Cancelof
Co-Applicant Primary Phone
Please enter a valid phone number.
Co-Applicant Alternate Phone
Please enter a valid phone number.
Co-Applicant Email Address
example@example.com
Co-Applicant Employer
Co-Applicant Employer Phone
Please enter a valid phone number.
The undersigned hereby applies to the City of Oak Grove for utility services and the City of Oak Grove agrees to furnish utility services for which services the undersigned agrees to pay a monthly rate and minimum charge as may be established by the City of Oak Grove, HWEA and Outlaw Disposal in accordance with applicable laws, ordinances and policies. It is understood and agreed the applicant will comply with all rates, schedules, rules, regulations and ordinances in connection with this service and the City of Oak Grove reserves the right, at any time, without notice, to interrupt service for maintenance, repairs or extensions without any liability to the undersigned or owner of such premises.

The undersigned agrees to pay the final bill once service is no longer needed or terminated for non-payment. If the final bill is not paid by the due date, a 35% collection fee will be added to the amount owed and the account will be turned over to a collection agency. If a credit is due the undersigned and a refund check is issued and subsequently returned to the City of Oak Grove as a non-deliverable, the undersigned agrees to allow the City of Oak Grove to donate the refund to the Plus One Program to help pay underprivileged utility customers bills in Oak Grove.

If the undersigned or a representative is not present when the utilities are turned on, the undersigned authorizes the City of Oak Grove to turn on the utilities without someone present and holds the City of Oak Grove harmless for any responsibility for any damages. Tamper fees are $100 for 1st occurence, $250 for 2nd occurence, $500 for 3rd occurence, and $750 for 4th occurence.
The undersigned agrees to pay a $150 deposit and $50 connection fee to establish service. All bills are due and payable monthly by the due date. A 10% penalty will be added to all bills not paid by the due date. The City of Oak Grove may discontinue service to any customer failing to pay for services by the termination date. Payments received on or after the termination date must be in cash, money order, or credit card and must include the full bill amount, the reprocessing fee of $50 plus any and all applicable fees prior to services being restored. Failure to receive a utility bill or final notice bill does not relieve the responsibility for payment by the undersigned. Initial below that you understand and acknowledge this statement.*
Utility bills are due on the 15th of every month regardless of receiving a utility bill or not. The last day to pay the utility bill is the 25th of every month as directed by your utility representative to avoid termination of services and a $50 reprocessing fee. You will be directed by your utility representative at sign up which billing cycle pertains to your address (Please note that online payments through the City of Oak Grove's website made after 11:00 PM CST take an additional business day to post to your account.)*
Applicant Date*

MonthDayYear
Date
Applicant Signature*

Clear
Co-Applicant Date*

MonthDayYear
Date
Co-Applicant Signature

Clear
***No further action is required once the application, drivers license and lease have been submitted. We will contact you within 24-48 hours of the requested start date to complete the application process.***

**Applications received after 3pm will be processed on the following business day**
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Application and Contract for Utility Services

Applicant Information

Co-Applicant Information