APP FOR OWNER

La Grange Utilities Commission

412 E. Jefferson St. La Grange KY 40031

APPLICATION FOR HOMEOWNER - A non-refundable origination fee is required.

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.
(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) *
(Phone Number) *
(Employer) *
(Phone Number)
(Billing Address, if different from above)
Co- Applicant Only those listed on this form may have access to account information.
Name

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

Month Day Year
Date
(Social Security Number)
(Email)
example@example.com
(Employer)
(Phone Number)
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. Ihave 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
(Date)

Month Day Year
Date
(Service Start Date) *

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