UBT :: Utilities Board of Tuskegee

Application Information (required)

Applicant's Last Name:

First Name:

Middle Name (full):

Suffix:

Today's Date: (dd/mm/yyyy)

Address where service is requested:

Mailing Address:

Home Phone:

Work Phone:

Date of Birth: (dd/mm/yyyy)

DL (State and Number):

SSN:

Current Employer:

Spouse/Next of Kin First Name:

Middle Name (full):

Maiden Name:

Spouse/Next of Kin SSN:

Spouse/Next of Kin Employer (Name and Address):

Applicant's Last Residence:

Name of the Electric Utility Supplier at Last Residence:

Have you or your spouse previously had services with the Utilities Board?: Yes No

If "Yes", provide previous name on account & previous service address:

Do you,the Applicant, own the property where service is requested: Yes No

If "Yes", then applicant must provide proof of ownership,such as a deed,a closing statement,property tax payment,etc. If "No", complete the Renter Information section.

Renter Information

Property Owner's Name, Address and Telephone #:

Other tenants living at the service address:

Note to Renter: Prior to connecting utility service(s),the applicant must provide a copy of his/her Rental/Lease Agreement,and a completed and executed Landlord Verification Form.

Student Information

Are you a Student: Yes No

If yes,provide the following student information:

Student ID #:

Name of Parent(s) or Next of Kin:

Mailing Address for Parent(s)/Next of Kin:

Telephone Number for Parent(s)/ Next of Kin (Include Area Code):

I, the undersigned, do hereby certify that the information provided herein is true and correct,and I do hereby authorize the Utilities Board to verify all information provided herein, to request and retain a credit report, and/or to request and retain utility payment history from my previous utility service providers.

I Agree: Yes No

Date: (dd/mm/yyyy)

Service Agreement

I, the undersigned, do hereby request that the Utilities Board of the City of Tuskegee (Board) provide utility services to the above service address. By signing this service agreement, I do hereby understand and agree that I am fully and personally responsible for the payment of all charges rendered for the utility services provided to the above stated service address in accordance with the rates, policies, rules and regulations as may beadopted from time-to-time by the Board. Further, I hereby understand and agree that if I shall at any time fail to pay, when due, any charges forservice or repairs, the Board may discontinue service without notice until all amounts owed are paid in full. Further, I do hereby understand andagree that if I have an unpaid balance due on any other account or at any other service address that said balance may be transferred to an active account of the undersigned and become a due and payable debt of said active account. Further, I do hereby understand and agree to pay all costs of collecting, securing or attempting to collect or secure the amounts owed, including reasonable attorney's fees, fees charged by the Board, collection agency fees and court costs. Further, by signing this agreement, I do hereby understand and agree not to permit anyone other than authorized agentsof the Board to connect, disconnect, test, install and/or remove or otherwise molest or tamper with the property/facilities of the Board. Further, by signing this agreement, I do hereby understand and agree that the breaking a meter seal, tampering or damaging an electric and/or water meter, and/or attaching any devices or using any other method which permits the flow of unmetered or unauthorized electricity or water to said service address is unlawful and that offenders will be subject to the payment of additional charges, damages and/or prosecution.

I Agree: Yes No

Date: (dd/mm/yyyy)


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