Rocky Mount

Instructions: Complete all pertinent fields, then read the information at the bottom of the form.

REQUIRED INFORMATION:

First Name:

Middle Name:

Last Name:

Phone Number:

Date of Birth:

Last four digits of SSN:

To turn-on Utility Services, please complete Section A and Deposit Requirements. Fax or email picture ID and lease (fax: 252-972-1521 or email: [email protected]).

SECTION A

Date to Turn On Services:

Service Address:

City:

State:

Zip Code:

Do you: Rent    Own

Landlord:

Realtor/Lawyer (to verify ownership):

Landlord's Phone:

Realtor/Lawyer's Phone:

Home Phone:

Spouse's Name:

Work Phone:

Employer:

Previous Address (including zip):

Check here if you would like to enroll in the Load Management Program.

To disconnect Utility Service, please complete Section B:

SECTION B

Location to Turn Off Services:

Date to Turn Off Services:

Location to Turn On Services:

Date to Turn On Services:

Home Phone:

Spouse's Name:

Work Phone:

Employer:

Services Requested:  Electric  Gas  Water  Area Light

SECTION C: Forwarding Address

House Number:

Street Name:

City:

State:

Zip Code:

Email:

Date:

Application must be received in the City of Rocky Mount Utility Business Office 3 business days prior to connection/disconnection request. A Customer Service Representative will contact you to confirm receipt of your application and to complete the application process.

Please contact our office if you have not received confirmation within 48 hours prior to your request, or if you have any questions. Our office hours are 8:30 a.m. to 5:00 p.m. Monday through Friday. Our telephone representatives are available at (252) 972-1250 from 8:30 a.m. to 7:00 p.m. Monday through Thursday and 8:30 a.m. to 5:00 p.m. on Friday.

For more information, or assistance with this form call 252-972-1250.

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