Start Service Rental Property - Merrimac Light Department

GENERAL INFORMATION

First Name *

Middle Initial

Last Name *

Email *

Phone *

This application is for the following service *

Residential

Business

Will this be a joint account? *

If you have a co-applicant.

Yes

No

Service Address *

Apt/Suite

Merrimac, MA 01860

BUSINESS SERVICE

Business Property Type *

The fee is held in escrow and will be credited to your final bill when service is stopped.

Is your billing address the same as above? *

Yes

No

Business Phone *

Previous Address *

Apt/Suite

City *

State *

Zip *

Name of Previous Electric Company *

Street Address *

City *

State *

RESIDENTIAL SERVICE

Service Address *

Apt/Suite

Merrimac, MA 01860

Residential Property Type *

The fee is held in escrow and will be credited to your final bill when service is stopped.

Is your billing address the same as above? *

Yes

No

Residence Phone *

Own or Rent? *

Own

Rent

Previous Address *

Apt/Suite

City *

State *

Zip *

Name of Previous Electric Company *

Street Address *

City *

State *

Are all residents of household 65 years of age or older?

No

Yes

Is electricity operated life-support equipment to be used in this residence? *

No

Yes

BILLING ADDRESS

First Name *

Middle Initial

Last Name *

Address *

Apt/Suite

City *

State *

Zip *

CO-APPLICANT INFORMATION

Optional Title

First Name

Middle Initial

Last Name

Phone

Email

APPLICANT SIGNATURE

CONSENT TO START SERVICE

IT IS EXPRESSLY UNDERSTOOD AND AGREED TO THAT THE APPLICATION IS NOT A CUSTOMER OF RECORD UNTIL (1) THIS APPLICATION IS COMPLETED AND ACCEPTED (2) ALL REQUIREMENTS OF THE RULES, REGULATIONS AND RATES OF THE DEPARTMENT HAVE BEEN COMPLIED WITH AND (3) ANY REQUIRED DEPOSIT HAS BEEN PAID IN FULL. FAILURE TO COMPLY WITH THESE CONDITIONS WILL RESULT IN IMMEDIATE TERMINATION OF SERVICE. THE UNDERSIGNED AGREES THAT THE APPLICANT WILL PROVIDE AT LEAST 10 DAYS NOTICE OF ANY INTENTION TO CLOSE THE ACCOUNT OR TERMINATE SERVICE AND THAT THE APPLICANT IS LIABLE FOR ANY AND ALL CHARGES FOR SERVICE UNTIL SUCH TIME AS THE DEPARTMENT OBTAINS ACTUAL METER
READINGS TO CLOSE THE ACCOUNT. THE UNDERSIGNED MAKES APPLICATION FOR UTILITY SERVICE AT THE PREMISES LOCATED AS DESCRIBED ABOVE. IT IS EXPRESSLY UNDERSTOOD THAT SUCH SERVICE WILL BE PROVIDED IN ACCORDANCE WITH THE PUBLISHED RULES AND REGULATIONS NOW IN EFFECT OR FROM TIME TO TIME AMENDED.

Applicant Signature

By signing, I confirm that this application has been prepared or examined by me. Under the pains and penalties or perjury, I declare that to the best of my knowledge and belief, it and all accompanying documents and statements are true, correct and complete.

Reset Signature

CO-APPLICANT SIGNATURE (If Applicable)

Co-Applicant Signature

By signing, I confirm that this application has been prepared or examined by me. Under the pains and penalties or perjury, I declare that to the best of my knowledge and belief, it and all accompanying documents and statements are true, correct and complete.

Reset Signature

Date *

IMPORTANT! Deposit Check Instructions

Please write a check for the deposit amount Payable to:
MERRIMAC MUNICIPAL LIGHT DEPARTMENT 10 West Main Street, Merrimac, MA 01860

Please write your new service address in the Memo area.

Your Start Service request will not be processes until your check is received.

You may also drop it off at our 10 West Main Street, Merrimac, MA 01860 address.

reCAPTCHA is required.

Start Service Form - Rental Property

GENERAL INFORMATION

Merrimac, MA 01860

BUSINESS SERVICE

RESIDENTIAL SERVICE

Merrimac, MA 01860

BILLING ADDRESS

CO-APPLICANT INFORMATION

APPLICANT SIGNATURE

CO-APPLICANT SIGNATURE (If Applicable)

IMPORTANT! Deposit Check Instructions