Ketchikan Public Utilities Commercial Form

Ketchikan Public Utilities

Commercial 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/Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your preferred contact method

Business Information
Business Name
Business Email
example@example.com
Guarantor

First NameLast Name
Guarantor Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Guarantor Email
example@example.com
Business Type
Business License Number
What is your EIN number?
Please list all authorized personnel that have permission to obtain any and all information, make changes to existing accounts and add additional accounts on the behalf of this business. This will remain in effect until we are notified in writing of any future changes.

Sole Proprietorship
Please list the individual responsible for payment of account(s):
Name

First NameMiddle NameLast Name
Email
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security Number
Driver's License Number
Birth Date

MonthDayYear

Service Information
Requested Service
Do you want the phone number and address published in the phone book?
Directory Listing Name
Example of business listing in the phone book:
KPU Telecommunications
2417 Tongass Ave Ste 119D
907-225-1000

Can be found under yellow page category: Internet Access Providers
Yellow Page Category for easy lookup
Optional Directory Listing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signatures
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. All costs incurred by the Municipality for the collection of any unpaid account shall be paid by the applicant. The information furnished on the application, including your social security numbers, are 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. 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, IPTV &/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 & IPTV Rates are based on twelve months continuous service with a minimum term of three (3) months.
Owner's Printed name
Date

MonthDayYear
Date
Drivers License

Cancelof
Owners Signature
Co-applicant's Printed Name
Co-applicant Date

MonthDayYear
Date
Co-applicant Signature
Should be Empty:

Rows	First Name	Last Name	Position	Phone Number	Email Address
Person 1
Person 2
Person 3
Person 4
Person 5

Rows	First Name	Last Name	Position	Phone Number	Email Address
Person 1
Person 2
Person 3
Person 4
Person 5

Ketchikan Public Utilities

Business Information

Sole Proprietorship

Service Information

Signatures