Service Application

 

1

BUSINESS INFORMATION:

 *

BUSINESS INFORMATION:

Business Name:	Business Type:
EIN No.:	NAICS Code:
Normal Business Hours:

2

OPERATION SCHEDULE:

 *

OPERATION SCHEDULE:

Monday	Thursday	Saturday
Tuesday	Friday	Sunday
Wednesday

3

CEO / PRESIDENT / OWNER'S CONTACT INFORMATION:

 *

CEO / PRESIDENT / OWNER'S CONTACT INFORMATION:

Name:	Office Phone No.:ext.
Mobile Phone No.:ext.	Email:
Business Mailing Address:

4

BILLING CONTACT INFORMATION:

 *

BILLING CONTACT INFORMATION:

Name:	Title:
Phone No.:ext.	Email (separate additional emails with a colon):

5

MONTHLY INVOICE DELIVERY PREFERENCE:

MONTHLY INVOICE DELIVERY PREFERENCE:

Printed, delivered by USPS

E-Bill, delivered via email

Both E-Bill & Printed

6

E-BILL DELIVERY ADDRESS(ES):

Email Address for E-Bill delivery (separate additional emails with a colon):

7

ON SITE CONTACT INFORMATION: 

 *

ON SITE CONTACT INFORMATION:

Name:	Title:
Office Phone No.:ext.	Email:
Construction Contact Name:	Construction Contact Phone No.:ext.
Construction Contact Email:

8

SERVICE INFORMATION:

 *

SERVICE INFORMATION:

Service Address:	APN No.:
Requested Service Start Date:	Construction Start Date:

9

SERVICES REQUESTED:

SERVICES REQUESTED:

Electric

Natural Gas

10

SERVICE TYPE:

SERVICE TYPE:

Permanent/ Operational	Temporary / Construction
New Construction	Existing Upgrade

11

SQUARE FOOTAGE:

 *

SQUARE FOOTAGE:

Office Space:	Warehouse:	Manufacturing:
Other:	Total:

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