METER REQUEST FORM

METER REQUEST FORM
TOWN OF SWEPSONVILLE

2747 DARREL NEWTON DR GRAHAM, NC 27253

PHONE (336) 578-5644

FAX (336) 578-5196
APPLICANT INFO
COMPANY NAME*
INSTALLATION INFO

Enter up to 5 service addresses where you would like a meter installed. If more spaces are needed, please complete additional forms. Residential meters cost $245/meter. The Town will contact the phone number below for collection of fees prior to installation.
SERVICE ADDRESS 1*
SERVICE ADDRESS 2
SERVICE ADDRESS 3
SERVICE ADDRESS 4
SERVICE ADDRESS 5
TOTAL NUMBER OF METERS REQUESTED*
DATE OF INSTALL REQUESTED*

MonthDayYear
Date
CONTACT INFO
BILLING ADDRESS*
BILLING CITY*
BILLING ZIPCODE*
PRIMARY PHONE NUMBER*
Will be contacted for collection of installation fees.
MOBILE PHONE NUMBER
EMAIL ADDRESS*
example@example.com
WOULD YOU LIKE TO HAVE YOUR BILL EMAILED?*

YESNO
SIGNATURE
DATE

MonthDayYear
Date
*Pursuant to 42 US.C. 405(c2Ci), Personal information collected by the Town of Swepsonville will only be used to ensure proper identification in the pursuit of delinquent charges. In no case will the information provided be shared, sold, or otherwise made available for public inspection. The disclosure of an applicant's social security number is voluntary.
Should be Empty:

APPLICANT INFO