Step 1 of 3 0% Request for electric service for Commercial, Agricultural Pump, or Business Account Date Service Needed (mm/dd/yyyy)(Required)(Please allow 24 hours, not including holidays or weekends) Month Day Year Service Address(Required)(Location of meter or address of building, etc.) Street Address Address Line 2 City State 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 ZIP Code Billing Address(Required)(Where you would like us to mail the statements and/or other information) Same as previous Street Address Address Line 2 City State 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 ZIP Code Meter Number Business Name Business Phone Number(Required) Persons Authorized to Discuss Information Regarding this Account Credit Information Please fill out either the corporate tax ID number or the individual(s) responsible for payment of account (guarantor).Corporate Tax ID Number(If the business is a Corporation, the Tax ID Number for the corporation will be used for credit purposes) Corporate Address(Required) Street Address Address Line 2 City State 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 ZIP Code Primary Name(Required) First Last Social Security Number PhoneDriver's License or ID Number State Employer Work Phone Agreement & ConsentApplicant Consent(Required) I hereby verify the above information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.I authorize Lassen Municipal Utility District (LMUD) to perform identity verification. I further authorize LMUD to conduct a credit check to determine eligibility for a waiver of the required deposit(s) in accordance with applicable policy(ies). I hereby apply for electric service to be supplied at the premises noted hereon, and promise to purchase and pay for same in accordance with the rates which shall from time to time be legally in effect, and to conform to and abide by the LMUD rules and regulations in force relating to the purchase of sale of said service. I understand that it is my responsibility to notify LMUD if I no longer wish to receive service, and acknowledge my responsibility for any charges incurred until such notification has occurred under the terms and conditions in effect. Applicant further agrees to pay all bills, in accordance with the LMUD terms of sale. Should suit be brought or legal action taken on same by an attorney or collections, applicant promises to pay a reasonable fee for such action, including all costs of the court, and attorney’s fees to the extent found by the court to be reasonable under the circumstances. Applicant Electronic Signature (Full Name)(Required)(By authorized individual or individual responsible for payment of account) Please note: Where service is being requested via an existing meter, service will be made available within three business days following fulfillment of all requirements of the district (including deposit or approval of waiver of deposit requirements) and the acceptance of the application for service (or as soon thereafter as desired). Requests for new construction or upgrades must be made via an appropriate application. Please use the appropriate form for these requests. (Forms available on our website or by contacting our office.) A connection fee of $25 will be charged for all connect or transfer requests involving an existing meter.
