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2. 
4. Application Date*
   Application Date
5. Service to begin*
   Service to begin
6. Applicant*

   1. Owner
   2. Tenant - $200. Security Deposit required with application, and must be paid by cash, check or money order.
8. Service Address*
10. Mailing Address, State & Zip (if different from service address)
14. Applicant Name*
15. Email Address
17. Driver's License or ID #*
18. Last 4 digits of SSN #*
20. Your preferred phone number will be used to contact you in the event of a service interruption, non-emergency matter, or billing issue.
21. Preferred Phone Number*
    -- Select One --CellHomeWork
22. Phone number with area code*
25. Additional Phone Number
    -- Select One --CellHomeWork
26. Phone number with area code
28. Applicant # 1 Signature
32. Applicant Name # 2
33. Email Address
35. Driver's License or ID #
36. Last 4 digits of SSN #
38. Phone Number, for Applicant #2
39. Preferred Phone Number
    -- Select One --CellHomeWork
40. Phone number with area code
43. Additional Phone Number
    -- Select One --CellHomeWork
44. Phone number with area code
46. Applicant # 2 Signature
50. Utility Billing and Collections – A $10. application fee will appear on your first Utility Bill. Bills are due the on last business day of the month. If payment is not received by the 1st of the following month, a 10% late fee will be added. If the bill is not paid within 35 days, service will be terminated. There is a $50. reconnect fee.
52. The $10. application fee will be waived, if the utility account was previously in your name.
53. Previous Cranberry Township address
57. Save $1. per month with E-bill and Auto Debit
59. Bank Name
60. Bank Account #
61. Routing #
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

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