APP FOR RENTER

La Grange Utilities Commission 412 E. Jefferson St. La Grange KY 40031

APPLICATION FOR RENTAL PROPERTY

Please complete form and an office employee will respond by email with an account number so you can register your account and pay the fee online. $45.00 non-refundable origination fee and $100.00 refundable rental fee.
(Address) *
Name *

(First Name) (Middle Initial) (Last Name)
(Date of Birth) *

Month Day Year
Date
Social Security Number
(Phone Number) *
(Email) *
example@example.com
(Emergency Contact)
(Emergency Contact Phone Number)
(Employer)
(Employer Phone Number)
(Landlord Name)
(Landlord Phone Number)
Co- Applicant Only those listed on this form may have access to account information.
Name

(First Name) (Middle Initial) (Last Name)
(Date of Birth)

Month Day Year
Date
(Social Security Number)
(Phone Number)
(Email)
example@example.com
By signing below, I ask that an account be opened by me. I will be bound by the Agreement received. I understand that when the service is turned off for non-payment of bill, the reconnection fee is $50.00. I have read the "Rules and Regulations", and "the Disconnection Policy" for customer service and agree to abide by them.
(Signature of Applicant)

Clear
(Date)

Month Day Year
Date
(Co Applicant Signature)

Clear
(Service Start Date) *

Month Day Year
Date
(Driver's License (ID) Number)
Pay online LaGrangeutilites.com
Should be Empty: