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)

Date

(Federal ID Number)

(Service Address)

(E Mail)

example@example.com

(Phone Number)

Format: (000) 000-0000.

(Bill to Address)

(Nature of Business)

(Contact Name)

(Phone Number)

Format: (000) 000-0000.

Is this property

IF THE HOME IS GOING TO BE A RENTAL PROPERTY, DOES IT NEED TO BE A READ AND LEAVE ON ACCOUNT (Anytime a tenant moves out, the property would default into the owner's name)

By signing below, I ask that an account be opened by me. I will be bound by the Agreement received. If this isa 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)

(Date)

Date

Complete only if Corporate Acct:

(Number of Years in Business)

(Signature & Title of Authorizing Corporate Office)

(Driver's License (ID) Number)

(Signature of employee receiving origination fee)

Pay online @ LaGrangeutilites.com