Application For Service - Fort Valley Utility Commission

APPLICATION FOR SERVICE
Applicant Information
New Service or Transfer Service ?
Check services desired:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
SS #
Driver's Licence #
Email
example@example.com

Authorized Person
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
SS #
Driver's Licence #
Phone Number
Format: (000) 000-0000.
Email
example@example.com

Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Connect Date

MonthDayYear
Date
If transfer, current address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Disconnect Date

MonthDayYear
Date
Billing address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you want to receive your statement(bill)?