Utility Services Application

UTILITY SERVICES APPLICATION

APPLICATION AND AGREEMENT FOR CITY SERVICES
Water / Wastewater / Natural Gas / Sanitation
Location Type:*

ResidentialCommercial
Location Relationship:*

OwnerBuilderRenter
Driver's License / Photo ID*

Government Issued Identification Card
Cancelof
Proof of Purchase / Lease Agreement Paperwork*

Paperwork showing ownership or lease of residence
Cancelof
Account
Applicant Name:*
Co-Applicant Name (If Applicable):
Service Address:*

Service Address

Apt, Suite, Box, Ect.

CityState

Zip
Mailing Address:*

Mailing Address

Apt, Suite, Box, Ect.

CityState

Zip
Applicant Home Phone:
Applicant Cell Phone:
Applicant Email:*
example@example.com
Applicant ID#:*
Applicant Date of Birth:*

MonthDayYear
Date
Applicant Social Security #:*
Co-Applicant ID#:
Co-Applicant Date of Birth:
Co-Applicant Social Security #:
Applicant Employer:*
Work Phone #:
Co-Applicant Employer:
Work Phone #:
Are you Industrial Sales Tax Exempt:

YesNo
Tax ID:
Tax Exempt Form

Tax Exempt Form MUST be a PDF
Cancelof
Emergency Contact

A Person NOT Residing at the Service Address
Emergency Contact Name:*
Emergency Home Number:
Emergency Cell Number:
INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the Federal Government to ensure the City’s compliance with certain Federal lending regulations. You are not required to furnish this information but are encouraged to do so. The City does not discriminate neither on the basis of this information or on whether you choose to furnish it.
Please select the racial category or categories with which you most closely identify by placing an “X” in the appropriate box. Check as many as apply.

American Indian or Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or Other Pacific IslanderI Do Not Wish to Furnish This Information
Please select the ethnicity category with which you most closely identify by placing an “X” in the appropriate box. Please only select one.

Hispanic or LatinoNot Hispanic or LatinoI Do Not Wish to Furnish This Information
I/We hereby make application to the City of Mount Pleasant Gas, Water, Wastewater, and Community Services Departments for any and all gas, water, wastewater, and sanitation services which are available at the location listed above or any other location or premises occupied or designated. I/We understand that the City of Mount Pleasant is only obligated to provide the applied-for services if the designated location is on or connected with the City of Mount Pleasant’s existing distribution lines or service areas.
GAS CUSTOMERS ONLY - MAINTENANCE OF CUSTOMER OWNED PIPING
The applicant agrees to permit authorized agents of the City of Mount Pleasant free access to the premises of the applicant for the purpose of inspecting, reading, repairing, or removing property of the City.

The applicant agrees that this application is subject to the City's Rules and Regulations, a copy of which is open for inspection at City Hall, and that these Rules and Regulations are part of this agreement.

In accordance with 40 CFR 192.16, all customers shall be aware and educated on the need to maintain customer owned piping. According to the Code, "maintain" means the customer is responsible to monitor for corrosion beginning at the outlet side of the meter set. If the customer's buried piping is metallic, then it is the customers responsibility to contact the Mount Pleasant Gas Department at (931) 379-7717 or after business hours (931) 379-3201 so that we can survey for leaks and if an unsafe condition is found, the Gas Department will shut off the flow of gas and advise the customer of the need to repair the unsafe condition. The Mount Pleasant Gas Department does not maintain the customer's buried piping. If the customer's buried piping is not maintained, it may be subject to the potential hazards of corrosion and/or leakage.

I/We hereby agree to pay all costs of collections, including attorney fees in the event of default in payment to the City of Mount Pleasant under the terms of this agreement or the Standard Rules and Regulations. The City has the right of offset on any monies owed me on any account to collect any amount owed to me. This agreement shall become binding upon execution by applicant, payment of applicable fees, and connection or commencement of services by the City.

All buried gas piping shall be: periodically checked for leaks, periodically inspected for corrosion if the piping is metallic, and repaired if any unsafe conditions are discovered. When excavating near buried gas piping, the piping should be located in advance, and the excavation should be performed by hand. The Mount Pleasant Gas Department can assist in locating and inspecting the customer's buried piping. Plumbers and Heating Contractors can assist in locating, inspecting and repairing the customer's buried piping.

I/We understand that information on this application may be used to obtain credit information and that my credit information may be used to determine the amount of my deposit. The City will not disclose this information without the customer’s prior written authorization.

I HAVE READ AND UNDERSTAND THE INFORMATION ABOVE AND HAVE ACCURATELY COMPLETED THE INFORMATION PRESENTED.
Signature

Clear
Date

MonthDayYear
Date
Application Received By
Date

MonthDayYear
Date
Gas Service Fee
Deposit Amount
Water Service Fee
Deposit Amount
Documents to Bring to City Hall

100 Public Square Mount Pleasant, TN 38474

Photo ID of Applicant and Co-Applicant (If Applicable)

Cash or Check Required for Secuiry Deposit

If Owner of Property: Proof of OwnerShip Documents

If Renting: Copy of Lease Required (Signed by Landlord and Tenant)

Please allow up to 2 (two) business days for residential services to be connected once you visit City Hall and your application is processed.
Should be Empty:

UTILITY SERVICES APPLICATION

Emergency Contact

GAS CUSTOMERS ONLY - MAINTENANCE OF CUSTOMER OWNED PIPING