Application for Service "*" indicates required fields Requested Start Date MM slash DD slash YYYY Primary Account Name* First Last Driver's License/Identification/Passport #* Issuing State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDate of Birth MM slash DD slash YYYY PhonePhone Home Cell Marital Status Single Married Separated Widowed Divorced Service Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Employer Name Work Phone #Joint Applicant Name First Last Joint Applicant Driver's License/Identification/Passport #* Issuing StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHiddenDriver's License/Identification/Passport #*Joint Applicant Date of Birth MM slash DD slash YYYY Joint Applicant PhonePhone Home Cell Joint Applicant Email Address Joint Applicant Employer Name Work Phone #Emergency Contact Person First Last Relationship Phone NumberTenant or Owner Tenant Owner Name of Landlord (if applicable) The undersigned requests the City of LaFollette Board of Public Utilities (hereinafter called LUB) to supply service, which shall include service at any location. Applicant agrees to receive and pay for all such services rendered or reserved for use of the undersigned when bills are rendered therefore in accordance with the rules of LUB in effect at the time the service is rendered. It is agreed that LUB may require, as security for the payment of bills, a cash deposit of such amount as it may deem adequate. The undersigned agrees to abide by and be subject to the rules and regulations of LUB relating to the service rendered pursuant to this contract. The undersigned agrees to grant a release of information to LUB for credit history, verification of service contract information, and any necessary collection action. The undersigned agrees to pay any and all collection fees, court costs, and reasonable attorney's fees incurred by LUB to perfect collection of a delinquent account. LUB may communicate with its Customers by all means of provided contact information, including but not limited to phone, text, email, etc. If Customer has provided a mobile phone number for calls or texts, the Customer's standard text and data rates shall apply. LUB may utilize an automated dialing system to provide informational, educational, and/or emergent messages. By providing the contact information, the Customer consents to LUB's uses as described here. LUB Customers may opt out of Customer notifications at their discretion by contacting LUB's Customer Service.Date* MM slash DD slash YYYY Signature of Applicant*Date* MM slash DD slash YYYY Signature of Joint Applicant*What is Caring Neighbors? Caring Neighbors is a program sponsored by LUB to help customers who are less fortunate pay their bills. Funds for the program come from voluntary contributions made by customers each month or as a one-time donation. It is an emergency assistance fund. It is not intended to be an ongoing source of extra income, but a temporary help to be used for paying bills. What is Operation Roundup? Operation Roundup is a program sponsored by LUB as a community fundraising program. Each month, customers elect to have their utility bills "rounded up" to the next highest dollar. For example, if your utility bill was $75.45, your bill would be rounded up to $76.00, with .55 going to the Operation Roundup fund. I want to contribute each month to Caring Neighbors. $1 $5 Other I want to round my bill each month up to the nearest dollar for Operation Round-up Yes No CommentsThis field is for validation purposes and should be left unchanged.
