Action Center / WMU Utilities Activation Form (Commercial) / Washington, IN

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WMU Utilities Activation Form (Commercial)

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About this Form

This is the commercial utilities request form

For additional information or questions on this form, contact Stacie Anderson.

* Denotes a required field

Commercial Utilities Activation Form

Please Do Not Complete The Following Field

IS THE SERVICE ADDRESS INSIDE OR OUTSIDE CITY LIMITS?

Business Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

City

State

Zip Code

Zip-Zip +4
Second portion of ZIP Code is optional.

Tax ID Number

Tax Exempt (If yes, form required)

Yes No

Telephone Number

Telephone Number Area Code-Telephone Number Prefix-Telephone Number Line Number ext Telephone Number Extension

Fax Number

Fax Number Area Code-Fax Number Prefix-Fax Number Line Number ext Fax Number Extension

Business Owner Information

Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

City

State

Zip Code

Zip-Zip +4
Second portion of ZIP Code is optional.

Email Address

Driver's License Number

Social Security Number

Date of Birth

Telephone Number

Telephone Number Area Code-Telephone Number Prefix-Telephone Number Line Number ext Telephone Number Extension

Billing Name and Address (If different from service address)

Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

City

State

Zip Code

Zip-Zip +4
Second portion of ZIP Code is optional.

Requested Date of Service Connection

Utilities Requested

Electric

Water

Sewer

Trash service provided by

Security Question/Answer

I have read through the above information and duly attest that the above responses are true. I understand that misrepresentation or omission of any facts or information called for on this application is subject to any and all City of Washington codes and/or ordinances. I understand that if such information is found to be false (fraudulent), the City of Washington will be bound to resolve this matter in accordance to its policies, codes, and/or ordinances, which may include any necessary fees or fines.

Signature

The City of Washington, Indiana

Small City... Big Possibilities

WMU Utilities Activation Form (Commercial)

About this Form

Commercial Utilities Activation Form

Business Owner Information

Billing Name and Address (If different from service address)

Dialog Title