Today’s Date - St. Charles, Minnesota
City of St. Charles—Utility Service Request Form
The City of St. Charles provides electric, water, sewer and garbage service.
Today’s Date __________________
Last Name ___________________________ First Name ____________________________ MI ________
Date of Birth __________________ Social Security # _____________________________
Drivers License Number _________________________________
Email Address ______________________________________
Daytime Phone # __________________________ Cell Phone # __________________________
Employer Name _____________________________ Employer Phone # __________________________
By signing this application, you agree to pay all charges associated with your utility account.
If not signed by the owner of the property, all adults over the age of twenty-one (21) intending to occupy the rental unit must sign this application and request for service, and will each be jointly and severally liable for any unpaid amounts. The City may refuse other service requests for any such adult, and may pursue collection against any one of the adults for the entire amount, in the event utility charges become delinquent.
Applicant Signature ______________________________________
Spouse / Additional Contact:
Name ___________________________________ Social Security # ___________________________
Signature ______________________________________
Name ___________________________________ Social Security # ___________________________
Signature ______________________________________
Date of Request
(Please allow 2-3 business days to complete this request. Utility service is activated Monday through Friday, excluding City Holidays.)
Preferred Service Activation Date ______________________
Service Address __________________________________ Unit Number _________
Services being requested (check all that apply)
Electric ______
Water / Sewer ______
Garbage cart ______ 35 gallon ______ 65 gallon ______ 95 gallon
Recycling cart ______ 65 gallon ______ 95 gallon
Mailing Address (If different than service address)
Address or PO Box ________________________
Unit Number ________________________
City ________________________
State ________________________
Zip Code ________________________
Meter Deposit requirements (must accompany application)
Date Paid
Residential Owner Occupied $50 __________
Residential Tenant $75 __________
Commercial $100 __________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- today s date in history
- on today s date in history
- subtract today s date from another date excel
- 90 days from today s date backwards
- format today s date in excel
- today s date formula in excel
- how to insert today s date in excel
- formula for today s date in excel
- how to get today s date in excel
- today s date celebrations
- today s date in number form
- excel formula today s date minus another date