APP FOR BUSINESS

La Grange Utilities Commission 412 E Jefferson St.

La Grange KY 40031 502-222-9325

Please contact office for amount of Origination fee/ Deposit
(Company Name)
(Service Start Date)

Month Day Year
Date
(Federal ID Number)
(Service Address)
(Phone Number)
(E Mail)
example@example.com
(Bill to Address)
(Nature of Business)
(Contact Name)
(Phone Number)
By signing below, I ask that an account be opened by me. I will be bound by the Agreement received. If this is a corporate account, both I and the company agree to be liable for all charges. If the service is disconnected for non-payment, the reconnection fee is $50.00. I have read the "rules and regulations" for customer service and agree to abide by them.
(Signature of Applicant)

Clear
(Date)

Month Day Year
Date
Complete only if Corporate Acct:
(Number of Years in Business)
(Signature & Title of Authorizing Corporate Office)

Clear
(Driver's License (ID) Number)
Pay online @ LaGrangeutilites.com
Should be Empty: