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Utility & Communications Application

Application for 2 signers

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Step 1 of 4 – APPLICANT AND SERVICE INFORMATION

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APPLICANT AND SERVICE INFORMATION

Type of Applicant(Required)
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.
Service Address(Required)
Same as service address
Billing Address(Required)
Employer Address
Send my invoice by email

SERVICES REQUESTED

Service Options
Heating
INTERNET OPTIONS
TELEPHONE OPTIONS
Long Distance Provider
PIC Lock
(prevent unauthorized changes)

Charges and Notes

Communications: Installation $30* | Reconnection $30 | Service change $10 | Technical visit $35

After-hours service $45/hour | Reconnection for non-payment $35. Other charges, taxes, and fees may apply.

UTILITY SERVICE AGREEMENT

  1. I agree to pay the minimum deposit of $200.00 and the transfer/connection fees before connecting electricity and/or water service. I understand that the deposit will be refunded after 12 months of on-time payments, in accordance with Section 403 B(5) of the LMU Policy.
  2. I agree to pay all invoices issued by Lenox Municipal Utilities for services provided from the start date until service is discontinued.
  3. All persons aged 18 or over residing at the service address and signing below are jointly and individually responsible for current and/or past-due LMU bills.
  4. I agree to notify Lenox Municipal Utilities when I wish to suspend service.
  5. I confirm that I have no outstanding LMU bills under my current name, any previous name, or my spouse’s current or previous name.

OTHER ADULT RESIDENTS (18 YEARS OR OLDER)

Name 1
Name 2
Name 3

CPNI CONTACT INFORMATION (COMMUNICATIONS CLIENTS).

Authorized users can access account information and request changes. Please list the authorized users.

SERVICE CONFIRMATIONS

All customers are jointly and individually responsible for the communication charges incurred in the direction of the service.

All residents aged 18 and over must sign and present valid identification before activating the service.

Connections are subject to a minimum connection charge of $30 plus tax.

Notice Regarding Unauthorized Charges: FCC rules allow you to block third-party billers and require them to separate their charges from your regular billing. Please review each bill and contact LMU if you have questions about any unknown charges.

Check what applies:

ACH payments are deducted on the 10th of each month; another authorization form is require.

REQUIRED FOR LEGAL SIGNING

Legal Consent(Required)
Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

CERTIFICATION AND SIGNATURES

By signing, I certify that the information is correct, I accept the applicable terms and authorize LMU to establish the selected services.

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