Application for Service

Application for Service

After application is submitted, you will receive an email from a staff member regarding required Gas and/or Water deposits.

This application must be submitted at least ONE business day prior to the date you would like services put in your name.

(Business days are Monday-Friday, except holidays.)

Date to Transfer Services*

Date

SERVICE ADDRESS

Street Address*

Ownership Status*

OwnRent

If renting, owner(s) name

PRIMARY APPLICANT

(Responsible for all decisions regarding this account)

Name*

First NameLast Name

Mailing Address*

City*

State*

ZIP*

Social Security Number*

Date of Birth*

Driver's License Number*

DL Issuing State*

Email Address*

Phone Number*

Employer*

Work Phone Number

SPOUSE

(Also responsible for this account)

Name

First NameLast Name

Date of Birth

Phone Number

ROOMATES

(18 years old & over)

Name

Phone Number

Name

Phone Number

EMERGENCY CONTACT

(Utility Emergency & we are unable to contact you)

Name*

Phone Number*

Utility Services Agreement

I hereby apply for utility services and agree to pay Emmetsburg Municipal Utilities all charges incurred in accordance with the rates, rules, and regulations in effect and on file with the utility. I understand that a deposit is required, which will be credited to my account upon the completion of 12 consecutive billing periods without any late charges. If the account is closed prior to the completion of this 12-month period, the deposit will be applied to the final bill, and any remaining credit balance will be returned to the primary account applicant.

I have read and understand everything stated on this application.

Signature of Primary Applicant*

Date*