Application For Utility Service

Service Request (check one) *
Applicant *
Last Name *
First Name *
MI OR Business Name
C/O or Person of Contact
Social Security Number/Tax ID
*Previous Address (If transferring service to new location or canceling service)
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date to Disconnect
Service Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Mailing Address (If different than Service Address) *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Telephone Number *
Alternate Phone Number
Email *

In consideration for receiving electric, gas, water, and/or sewer service from Dalton Utilities, at the above location, I hereby acknowledge responsibility for payment of service billings. *
I agree
Accounts are billed on a monthly basis and payment by the indicated due date is required to prevent interruption of service. I am responsible for electric, gas, water, and/or sewer service until the account is closed. *
I agree
I have read and agree to the terms and conditions. I further understand that applications will not be processed without appropriate identification, documentation and payment. *
I agree

Account#
WO#
Closing Date/Beginning Lease Date
(Documentation Required)
Deposit
Service Fees
Total Amount
Location Services
Electric, Gas, Water, SewerWater & SewerWater OnlyElectric OnlyGas Only