CITY OF SOUTHPORT

201 E. MOORE ST

SOUTHPORT, NC  28461

(910) 457-7900 (910) 457-7905 (FAX)

UTILITY APPLICATION  

APPLICATION DATE:__________________________         TURN ON DATE:__________________________

____RENT  (OR) ____OWN        ***A PHOTO COPY OF YOUR DRIVER'S LICENSE IS REQUIRED***

REQUESTED SERVICES FROM UTILITY COMPANY: (PLEASE CHECK ALL SERVICES REQUESTED)

ELECTRIC______, WATER______, SEWER______, GARBAGE_______    

ACCOUNT NUMBER (ASSIGNED BY CITY)__________________________

(1). NAME(S):___________________________________________________________

     EMAIL:___________________________________________________________ DATE OF BIRTH___________________

(2). DRIVERS LICENSE #:__________________________  ***SSN#____________________________ 

(3). SERVICE ADDRESS:___________________________________________________________________________

(4). MAILING ADDRESS:__________________________________________________________________________

     CITY:_________________________________     STATE:_____________  ZIP CODE:__________________

     PHONE:_________________________ ALTERNATE PHONE:___________________________

(5). EMPLOYER:______________________________________________________________________

    

      ADDRESS:____________________________________________________________ CITY:______________________________

      STATE:_______________    ZIP CODE_________________      WORK PHONE:___________________________

(6). PRIOR UTILITY COMPANY:_______________________________________________________________

I HEREBY MAKE APPLICATION FOR UTILITY SERVICES AS INDICATED AND THE PREMISES INDICATED.I AGREE TO COMPLY WITH THE APPLICABLE ORDIANCES OF THE CITY OF SOUTHPORT REGARDING THE PROVISION OF UTILITY SERVICES, INCLUDING THOSE RELATING TO DEPOSITS AND OTHER CHARGES.

I UNDERSTAND THAT THE INFORMATION FURNISHED ON THIS APPLICATION WILL BE VERIFIED AND IF DETERMINED INACCURATE, WILL RESULT IN THE TERMINATION OF SERVICE WITHOUT PRIOR NOTICE.

***BY PROVIDING YOUR SOCIAL SECURITY NUMBER IT WILL BE USED TO FACILITATE CREDIT REPORTS AND COLLECTION OF ELECTRIC, WATER, SEWER, GARBAGE, PRIVILEGE LICENSES, & PROPERTY TAXES OR ANY OTHER BILLS IN THE EVENT YOU DO NOT PAY THE BILL VOLUNTARILY. USING THE PROVIDED

SOCIAL SECURITY NUMBER WILL ALSO ALLOW THE CITY TO CLAIM PAYMENT ON ANY UNPAID BILL FROM THE NC DEBT SETOFF PROGRAM AND OR OTHER COLLECTION METHODS NECESSARY TO SATISFY ANY UNPAID DEBT.

CUSTOMER SIGNATURE(S):_______________________________________________________________

APPROVED:__________________________________________________________