New Service Form – Residential

APPLICATION FOR SERVICE

Charles Town Utility Board
661 S George Street, Charles Town, WV 25414

Items required to setup new service:
Picture ID for all adults (18+ years of age)
Proof of residency. If renting — rental or lease agreement signed by all parties. If purchasing — any document displaying applicant as the owner of the property.
Application signed by all adult tenants if renting or property owner if purchasing
Deposit. Amount varies, please check with cashier
IDs for all adults listed on lease or deed are required

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Driver's License *

Drag & Drop Files, Choose Files to Upload

Proof of Residency *

Drag & Drop Files, Choose Files to Upload

Name *

First

Middle

Last

Drivers License State

Drivers License Number

Address for Service *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Address for Bill *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Home/Cellphone *

Email Address *

Secondary Phone

Own or Rent Location *

• Own
• Rent

Landlord's Name

Landlord's Phone

Date Service is to Start *

Service can be stopped or started during business hours only.

Date *

Submit