CITY OF STATESVILLE - UTILITY SERVICE APPLICATION
Applicant’s Legal Name: _______________________________________________________
Social Security Number: ___________________ Driver’s License Number: ______________
Telephone Number: ______________________ Date of Birth: _________________________
Name of Spouse/ Roommate: ___________________________________________________
Social Security Number: ____________________ Driver’s License Number: _____________
**COPY OF RENTAL AGREEMENT OR PROOF OF OWNERSHIP REQUIRED**
Do you: Own Residence ____ Rent Residence ____ Utility start date
SERVICE ADDRESS: __________________________________________________
Mailing Address if Different From Service: _______________________________________
Have you ever had service with the City of Statesville before? ____yes ____no
If so where and when? __________________________________________________
Present Employer: _________________________ Work Phone _________________
Spouse’s Employer: ________________________ Work Phone _________________
Name of other adults living at this address: __________________________________
I hereby make application for utility services at the premises indicated for residential purposes
only. I agree with the applicable ordinances of the City of Statesville regarding the provision of
utility services, including those relating to deposits and other charges.
I understand that the information on this application will be verified and if determined inaccurate
will result in the termination of service without prior notice.
Applicant’s signature ______________________________ Date __________________
City of Statesville Representative ___________________________________________
Customer # - Location # ________________________