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MUNICIPAL UTILITIES COMMISSION
PO Box 119
3 Broad Street
Hamilton, New York 13346
Telephone: 315-824-1111
Fax: 315-824-0922
APPLICATION FOR UTILITY SERVICE
The Village of Hamilton Municipal Utilities Commission is hereby requested to furnish the undersigned with (whatever applies) electric, water, and sewer. Such service(s) are to be supplied by the Commission under the rules and regulations as filed with the Public Service Commission and available for inspection at the Village Office. The undersigned agrees to pay for services in accordance with applicable service classifications.
The applicant also understands and acknowledges that this application is in fact a credit application. As such it must be completely and accurately filled out and signed. The applicant is responsible for timely payments of all bills to the Commission, and to see that any change to the information given below is reported to the Commission office. The applicant is responsible for advising the Commission office in advance if he/she is leaving the premises. Failure to notify does not excuse responsibility for subsequent service bills.
Name: __ ___ Service Address: _
Mailing Address: ___ __ Apartment # and location:
_______ Date Service is to Begin:
Telephone No -- Home:
Cell: _
Social Security No:
Are you (check one)? Residential Owner, Residential Renter, Commercial Owner, Commercial Renter.
Name of Landlord
If you lease, what is the term of your lease?
Are you presently employed? . If so, where?
Are you currently enrolled as a student? .
Date of birth: Do you receive public assistance or SSI benefits? .
If so, please describe the benefit and give the address of the office you receive benefits from:
Are there any of the following at Dependent Children under 18 years of age: Yes No .
the service address? A handicapped occupant: Yes No .
A life support system: Yes No .
An occupant 62 years of age or older: Yes No .
Factual circumstances indicating any other
serious or hazardous health situations that
would be affected by a power outage: Yes No .
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Have you ever resided in the Village of Hamilton utility district before? Yes No
If yes, what address? _____________________________________________________________________________
Name and address of previous supplier of electricity, if any:
REMINDER: If this credit application is not filled out completely and accurately, service may be denied.
If you are a Colgate student, please furnish us with your home address and phone number for final bill mailings.
Address
Phone
APPLICANT’S SIGNATURE: _________________ Date:
FOR OFFICE USE:
Deposit required? Yes No . Amount of Deposit: ______ Date Paid ________________
COMMENTS/NOTES