CITY OF
APPLICATION FOR UTILITY SERVICE
Date Service to Begin: ___________________ Service
Address_______________________
I hereby certify that I am the (check one)
owner [
] tenant [ ]
of the above described property and
that I do hereby accept and will comply with all the rules, ordinances
and regulations which may be
prescribed by the City relating to water, garbage, and sewer service and
distribution.
Pursuant to Pocatello Municipal
Code, all new customers or customers with adverse credit with the City are
required
to post a
$65.00 utility service deposit for a
single family residence, or a
$130.00 utility
service deposit for a multi-unit (provide Deed Of Trust or Warranty Deed), or a
$130.00 utility service deposit for a commercial
account.
Said deposit shall be applied toward
the account balance after 12 consecutive on time payments, or applied to the
account upon closure.
PLEASE PRINT CLEARLY AND COMPLETE ALL
INFORMATION LISTED BELOW:
Drivers License #
______________________ State Issued ______________________________
Applicant Name (please print)
______________________________________________________
Signature of Applicant: ____________________________________________________________
**Name on the Account:
____________________________________________________________
Social Security
Number: __________________ Federal Tax
ID (if applicable) _______________
Name of Employer:
_________________________ Address:
_____________________________
Applicant Home Phone:
_____________________ Business Phone: _______________________
Billing Address if different than Service Address: ______________________________________
Name of Spouse (if applicable):
_____________________ Spouse Employer: _______________
Social Security Number of Spouse:
__________________ Business Phone: _________________
Reference Person (local)
___________________________ Address: ________________________
Phone Number: ______________________ Relationship to Applicant: ____________________
**Note: Accounts to
be established under the name of a
“limited liability company” or LLC, are required to provide
Additional information for review by
the City’s Legal Department. The LLC
information is available upon request.
A deposit
in the amount of $__________ is [ ] is
not [ ] required. If required, the deposit can accompany the
application by mail to Utility
Billing, City of Pocatello, P.O. Box
4169, Pocatello, ID 83205-4169, or if you wish
to fax the application, the deposit
can be paid by Visa or Mastercard
by phone. Please fax your application to
208-234-6577. Services will not be
effective until the deposit is received.
Questions can be directed to (208)234-6241
between 8:00 a.m. and 5:00 p.m. Monday through Friday. Thank you!