205 S Main St Lenox IA 50851

Ph: (641) 333-2550 Fax: (641) 333-2582 [email protected]

APPLICATION FOR UTILITY SERVICE FOR TENANTS TENANT NAME SERVICE ADDRESS PROPERTY OWNER HOME TELEPHONE #

WORK TELEPHONE #

EMPLOYER

SSN #

E-MAIL ADDRESS I hereby apply for

ELECTRIC

WATER

service(s) for the service address

listed above pursuant to the following conditions:

1)

I agree to pay the minimum deposit of $200.00 (two hundred dollars) and transfer fees/ connection fees prior to service connection for electric and/or water service.

2)

I agree to pay all bills rendered by Lenox Municipal Utilities for services provided beginning to the date the service is discontinued.

3)

In addition to the applicant's signature, I understand that all persons over the age of 18 who reside at this service address and whose signatures appear below are jointly and independently responsible for payment of any current and/or delinquent bills rendered by Lenox Municipal Utilities.

(Today's date)

Name:

SSN #

Name:

SSN #

Name:

SSN #

4)

I agree to give notice to Lenox Municipal Utilities of my intent to discontinue service.

5)

I hereby verify that I have no outstanding bills with the Lenox Municipal Utilities under my current name or any other name I have used in the past, or under a current or former spouse's name.

Lenox Municipal Utilities Representative

Date

Tenant Signature