Ketchikan Public Utilities Residential Application

Ketchikan Public Utilities

Residential application
Name

First NameMiddle NameLast Name
Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your service address the same as your mailing address?
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Landline Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your preferred contact method

Personal information
Date of Birth

MonthDayYear
Social Security Number
Driver's License Number
Driver's License State
Please upload a picture of your Driver's License

Cancelof
Employer
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Will there be a Co-Applicant on this application?

Co-Applicant
Name

First NameMiddle NameLast Name
Email
example@example.com
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Landline Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date

MonthDayYear
Social Security Number
Driver's License Number
Driver's License State
Please upload a picture of your Driver's License

Cancelof
Employer
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Service Information
Requested Services
Do you want the phone number and address published in the phone book?
Name To Publish

First NameLast Name
Address To Publish

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you rent or own the property at this address?

Signatures
By signing below I am certifying that this is my accurate service address. If this address is found to be incorrect, I agree to pay for all electric fees and charges incurred at the incorrect address due to my error. The minimum fee charged would be an $105.85 cut in fee.
The undersigned certifies that he/she is the owner-lessee-tenant of the premise where service is applied for with lawful authority to sign this application for utility service & agrees to pay the applicable rates & abide by the terms & conditions as prescribed by the Municipal Ordinance & Utility Tariff for all present & future utility service. Acceptance of the application by the Municipality of Ketchikan constitutes a contract between the Municipality & applicant. The applicant shall pay all costs incurred by the Municipality for the collection of any unpaid account. The information furnished on the application, including social security numbers, is voluntary and will be used to determine if a deposit will be required. Your signature in the designated space authorizes the Municipality to conduct a credit check if such action is necessary in order to determine the possible deposit requirements. Failure to provide information will automatically require a deposit. In the event more than one party is applying for the service, KPU may, in its sole discretion, make any deposit solely and fully payable to the applicant with the co-applicant waiving any claim against KPU for paying the full deposit to the applicant. I hereby declare that the information provided is true, accurate & complete to the best of my knowledge & belief & is voluntarily submitted for the purpose of receiving telephone, internet, &/or utility service. It is understood that upon presentation of the application it becomes the property of the Municipality. I also certify that I am eighteen (18) years of age or older. All Residential & Business Telecommunication & DSL rates are based on twelve months continuous service with a minimum term of three (3) months.
Applicant's Printed Name

First NameLast Name
Applicant's Date

MonthDayYear
Date
Applicant's Signature
Co-Applicant's Printed name

First NameLast Name
Co-Applicant's Date

MonthDayYear
Date
Co-Applicant's Signature
Should be Empty:

Ketchikan Public Utilities

Personal information

Co-Applicant

Service Information

Signatures