Application for Services

FOR OFFICE USE ONLY ACCOUNT #

[ ] LEASE/RENTAL AGREEMENT

[ ] PREVIOUS DEBT DEPOSIT FILE #

[ ] PHOTO ID Required items needed to establish service:

[ ] GCSSD Deposit **PHOTO ID**

[ ] BPWD Deposit **COPY OF LEASE/RENTAL AGREEMENT***

PAID DATE: /

CASH OR CHECK # ______

APPLICATION FOR SERVICES

GRANT CO. SANITARY SEWER DISTRICT BULLOCK PEN WATER DISTRICT

P.O. BOX 460 P.O. BOX 188

CRITTENDEN, KY 41030-0460 CRITTENDEN, KY 41030-0188

(859) 428-3060 (859) 428-2112

$100.00 DEPOSIT REQUIRED $100.00 DEPOSIT REQUIRED

1.)  NAMES ON LEASE OR DEED:______DATE: / /

*******NAMES APPEARING ON ACCOUNT MUST BE ALL INDIVIDUAL(S) ON LEASE OR DEED******

2.)  ADDRESS OF SERVICE:______

3.) BILLING ADDRESS (IF DIFFERENT FROM ABOVE):______

4.)  TELEPHONE NUMBER:______

5.)  SOCIAL SECURITY NUMBER:______

6.)  DRIVER’S LICENSE NUMBER:______

7.)  PAST ADDRESS:______

Street City State Zip

8.)  OCCUPATION:______

9.)  EMPLOYER:______

Address:______

Length of Employment:______

Annual Salary: Less than 20,000 [ ]

20,000 to 30,000 [ ]

Over 30,000 [ ]

9.) HAVE YOU BEEN A CUSTOMER OF BULLOCK PEN WATER DISTRICT OR GRANT CO. SANITARY SEWER DISTRICT? [ ] Yes [ ] No

10.) IF YES, When______Address:______

11.) IF YOU RENT, PRINT LANDLORD’S NAME:______

12.)NAME(S) OF ADULTS LIVING AT ADDRESS:______

13.) NUMBER OF INDIVIDUALS TO BE LIVING AT PLACE OF UTILITY SERVICE:______

14.) PRIMARY USE OF UTILITY SERVICE: [ ] Residential [ ] Commercial [ ] Other

15.) HAVE YOU FILED ANY BANKRUPTCY ACTION WITHIN THE PAST 7 YEARS?

[ ] Yes [ ] No (If yes, please give details on reverse side.)

16.) HAVE YOU EVER HAD A UTILITY SERVICE (water, gas, electric, phone, cable) DISCONNECTED IN THE PAST DUE TO NON-PAYMENT?

[ ] Yes [ ] No (If yes, please give details on reverse side.)

DATE:______SIGNATURE OF APPLICANT:______

***Please identify individuals in whose name the account will appear and who will be responsible for payment of charges. Payments are mailed to the above address.

ALL SEWER BILLS ARE DUE THE 20TH OF EACH MONTH. ANY BILLS NOT PAID BY THE DUE DATE ARE SUBJECT TO A 5% PENALTY OF THE SEWER BILL. ANY BILL NOT PAID WITHIN 15 DAYS AFTER DUE DATE, WILL BE SHUT OFF WITHOUT ADDITIONAL NOTICE, AND CHARGED A $35.00 FEE FOR RECONNECTION.

I HAVE RECEIVED A COPY OF THE RULES AND REGULATIONS OF THE GRANT CO. SEWER SERVICE.

DATE:______SIGNATURE OF APPLICANT:______