ALL INFORMATION MUST BE COMPLETED

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TOWN OF BARGERSVILLE
PO Box 420 – Bargersville, IN 46106
Phone: (317) 422-5115 – Fax (317) 422-5117
www.townofbargersville.org - [email protected]
POWER & LIGHT – WATER WORKS - SANITATION DEPARTMENT – STORM WATER
APPLICATION FOR COMMERCIAL – NON RESIDENTIAL SERVICE
Please print or type the following information:
Application Date: ______________________
Service Connection Date: _______________
CUSTOMER INFORMATION
NOTICE
A deposit will be required for Utility service to be established
The deposit will be applied to the final bill at time of service termination
Business/Owner Service Application
Name of Business/Owner: _______________________
Tax ID/SSN#: _________________________________
Tax Exemption: Yes No Indiana Form ST109 (Required)
Address: _____________________________________
City: ________________________________________
State: ____________ ZIP: _______________
Email: _______________________________________
Business Phone: (____) __________________
Business Fax: (____) __________________
Primary Contact Name: ________________________
Primary Contact Phone: (____) __________________
Co-Owner Name: ______________________________
Co-Owner SSN#: ______________________________
Mailing Address, if different
Address: ____________________________________
City: ________________________________________
State: ____________ ZIP: _______________
Address of Business Property Receiving Utility Service
Address: _____________________________________
City: _________________________________________
State: ______________ ZIP: ______________
Property Contact Name: _________________________
Property Contact Phone: (____) _______________
Please select appropriate Business/Owner Type
___ Tenant (Please provide a copy of lease/rental agreement)
___ Landlord (Complete a Rental Property Owner Agreement)
Business Type
_____ Retail
_____ Wholesale
_____ Manufacturing
_____ Church
_____ Service
_____ Distribution
_____ Office
_____ Other
Planned Changes
_____ Structure
_____ Plumbing
_____ Floor Drains
_____ Electrical
_____ Upgrade Elect
_____ HVAC
_____ Other
Business Property Use(s)
___ Alcohol Sales/Beverages
___ Bale/Loose Combustible Fiber
___ Cellulose Nitrate Film
___ Compressed Gas
___ Dry Cleaning (Flammable Solvents)
___ Dust Producing Processes
___ Explosives/Ammunition/Fireworks
___ Flammable/Combustible Liquids
___ Food/Beverage/Food Products
___ Liquid Propane Gas
___ Other Hazards
___ Poisonous/Hazardous Chemicals
___ Recycling Waste
___ Smoking
___ Vehicle Repair/Garage
___ Welding/Cutting
___ Woodworking
___ X-Ray Developments
Landlord/Mortgage Company
Name: ________________________________________
Address: _____________________________________
City: _________________________________________
State: ______________ ZIP: ______________
Phone: (____) __________
By signing below I verify the information is correct to the best of my knowledge and agree that if I am a customer with Greenwood Sanitation,
this application and/or information contained herein may be shared with the City of Greenwood.
_____________________________________________
Owner/Company Representative
Date
_____________________________________________
Co-Owner/Company Representative
--------------------------------OFFICE USE ONLY------------------------------
Meter Deposit: WTR ______ IRR ______ ELE ________
Amount: _____________ Receipt # ________________
Processed by: _____________________ Date: _______
Service Order # ________________________________
Date
Account # _______________________________
Subdivision _______________________________
Lot # ______________
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