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)*

MonthDayYear
Date
(Federal ID Number)
(Service Address)*
(E Mail)*
example@example.com
(Phone Number)*
(Bill to Address)*
(Nature of Business)*
(Contact Name)*
(Phone Number)*
Is this property*

Rental PropertyCommercial PropertyOther
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)

YesNo
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)*

Clear
(Date)*

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

Clear
(Driver's License (ID) Number)
(Signature of employee receiving origination fee)

Clear
Pay online @ LaGrangeutilites.com
Should be Empty: