City of Eskridge

110 S. Main w p.o. Box 156

Eskridge, ks 66423

Telephone 785-449-2621 w fax 785-449-7289

Utility Service Application

Primary Applicant (last, first, middle)	Date Service is to start
Physical Address Where Utility is Located	Mailing Address (if different from physical address)
OWN RENT	Landlord Name, Address, and Phone
Previous Address
Social Security #	Driver’s License #
Home Telephone	Work Telephone
Employer	Employer Address
Number of persons in household

CURRENT PHOTO ID, SOCIAL SECURITY NUMBER, COMPLETED APPLICATION AND DEPOSIT REQUIRED AT THE TIME OF CONNECTION.

Co-Tenant Information required. Persons listed as co-tenants will be responsible for the utility service in the event of default by the primary applicant.

Secondary Applicant (last, first, middle)	Social Security #
Employer	Driver’s License #
Employer Address	Work Telephone

Pet Information – Residents in the City of Eskridge

(Tags are required on all dogs owned by you. Pit Bulls are prohibited in City limits per ordinance #441. There is a limit of no more than 4 dogs per household.)

Dogs Name(s)

Breed/Sex

Rabies Vaccine Expiration Date

Color

Spayed/Neuter

(OVER)

Applicant(s) understand that the use of said utility services will be governed by the ordinance of the City of Eskridge, Kansas, that the present rates may be changed from time to time by action of the Governing Body of the City, and that the City does not warrant and insure the uninterrupted service of any utility. Applicant agrees to abide by all laws and ordinances concerning the use and prompt payment for such utility service.

The Privacy Act regulates the use of Social Security Numbers by government agencies. The City of Eskridge requires the disclosure of Social Security Numbers upon completing a service application. The SSN may be used to collect delinquent account balances through the State of Kansas Setoff Program or contracted collection agency. No other use or distribution of SSN will be allowed. Failure to disclose required SSN will result in denial of utility services.

Signature (Primary Applicant): __________________________________________

Signature (Secondary Applicant): ________________________________________

NOTICE: Excess Flow Valve: (Only applicable to new or replaced service.)

The safe delivery of Natural Gas remains a primary mission of the City of Eskridge. To help accomplish this fundamental task, the City is taking safeguards to minimize occurrences of blowing gas due to pipe line breaks caused by third party damage and natural disasters. The easiest, most dependable, and economical way is with an (EFV) excess flow valve. An EFV is designed to shut off the flow of natural gas automatically if the service line breaks. The service line is the line from the gas meter to the main connection. An EFV is available that meets DOT performance standards if the customer is willing to pay the costs of installation.

The EFV device is installed on residential services lines next to the gas main. There could be maintenance involved with this device and replacement cost is also at the customer’s expense.

If the customer requests the installation of the EFV, the customer bears all cost associated with installation. Installation cost is $190.00 payable when you sign up for service or if requested otherwise. Also, there will be cost associated for maintenance and replacing the EFV as required. Estimated cost of replacement is approximately $250.00 and maintenance, if needed, could cost approximately $150.00 to $250.00.

PLEASE INSTALL AT THE COST OF $190.00 _______________________________DECLINE__________________________________

(APPLICANT’S SIGNATURE) (APPLICANT’S SIGNATURE)

City Use Only

Service ID/Account #_____________

Gas _________ Water_________ Sewer _________ Trash _________

Total Deposit $______________ Service Charge $_________ Total Due $_____________

Amount Paid $_______________ Date _____________

Amount Paid $_______________ Date _____________

Amount Paid $_______________ Date _____________