Utilities Service or Transfer of Service Application

ACCOUNT BILLING INFO	DATE:	ACCOUNT TYPE : RESIDENTIAL  COMMERCIAL
	ACCOUNT TITLE: (TO APPEAR ON BILL FOR COMMERCIAL CUSTOMERS ONLY)

NAME:  SPOUSE:  (TO APPEAR ON BILL FOR RESIDENTIAL CUSTOMER)

CONTACT PERSON	MAILING ADDRESS (IF DIFFERENT FROM CONNECT)
	DRIVERS [s1] LICENSE:

TELEPHONE

# HOME

# WORK

SOCIAL SECURITY #

DATE OF BIRTH

CONNECT INFO	DATE OF CONNECT	LEASING	OWN
	ADDRESS

TRANSFER INFO	ADDRESS TO DISCONNECT
	DATE OF DISCONNECT NO MORE THAN 5 BUSINESS DAYS AFTER THE NEW CONNECT

HAVE YOU EVER HAD CITY OF BASTROP UTILITIES BEFORE? YES NO

IF SO, AT WHAT ADDRESS

HOUSEHOLD INFO	# OF BATHS	# OF BEDROOMS	# IN FAMILY
	SPRINKLER SYSTEM YES / NO SWIMMING POOL YES NO

SPECIAL NEEDS OF OCCUPANT

THE UNDERSIGNED AGREES TO PAY ALL DEPOSITS AND FEES ESTABLISHED BY THE CITY OF BASTROP AND UNDERSTANDS BILLING POLICY. SIGNATURE : _______________________________________________________________

OFFICE USE ONLY	Electric deposit #	Amount	LEASE DEED
	Water deposit #	Amount	YES NO