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Public Utilites Application

TOS Public Utilites Application

TOWN OF SHIPSHEWANA PUBLIC UTILITES APPLICATION

345 Morton St., Shipshewana, IN 46565
Phone: (260) 768-4743 x701
utility@shipshewana.gov

Account Type

Business

Residential

Are you renting?

Yes

No

Is this a stormwater only location.

Yes

No

CUSTOMER INFORMATION

First Name(s)

Last Name

Mailing Address

City

State

Zip Code

Email

Phone/Mobile

Phone Type

Cell Phone

Home Phone

**A Government Issued ID is Required

State ID/Drivers License Number

State of Issue

Upload a image of the front and back of your state issued ID.

Choose File

Previous Address

City

State

Zip Code

This section for business applicants only

Corporation Name

DBA Name

Federal Tax ID

Retail Merchant Certificate

Org Type (Choose one)

LLP

LLC

S Corp

C Corp

Other

LOCATION INFORMATION

Utility Location Address

City

State

Zip Code

Utility Services Requested

Water

Wastewater

Stormwater

Additional Services Requested

Irrigation Water

Fire Sprinkler Service

Private Hydrant

Date Service to Begin

Deposit Amount

Have you applied for service connection with the Town of Shipshewana Public Utilities in the past?

Yes

No

If yes, state the date(s) and address(es) below:

RENTAL INFO

Current Landlord - First Name

Last Name

Current Landlord Address

City

State

Zip Code

Email

Phone/Mobile

Previous Landlord - First Name

Last Name

Email

Phone/Mobile

Reference 1: First Name

Last Name

Reference 1: Address

City

State

Zip Code

Reference 1: Phone/Mobile

Reference 2: First Name

Last Name

Reference 2: Address

City

State

Zip Code

Reference 2: Phone/Mobile

Reference 3: First Name

Last Name

Reference 3: Address

City

State

Zip Code

Reference 1: Phone/Mobile

EMERGENCY CONTACT (Not living with you)

First Name

Last Name

Phone/Mobile

Phone Type

Cell Phone

Home Phone

IMPORTANT INFORMATION – PLEASE READ

Any account set up after 3:00pm that has been disconnected will not be scheduled for re-connection until the following business days.

I am applying for utility services from the Town of Shipshewana at the above address. I agree to follow and abide by all rules for utility service and to pay charges in effect as stated on each monthly bill.

I hereby certify that read I the contents of the above statements and affirm under penalties for perjury that the same are true and correct. I also hereby authorize the Town of Shipshewana Public Utilities to seek details on my character background and credit history as it deems necessary and a photocopy of this shall be sufficient authority to release any such information to the Town of Shipshewana Public Utilities.

I understand that non-payment of my account will result in discontinuation of service and that I will incur an additional shut off and turn on fee.

Signature

Sign Here

Printed Name

Date

FORMS

Public Utilites Application
Golf Cart/ORV Permit
Facility License Application
VIN/HIN Check

SHIPSHEWANA CIVIL TOWN | Shipshewana, Indiana | 260-768-4743 | Tax Exempt

TOWN OF SHIPSHEWANA PUBLIC UTILITES APPLICATION

CUSTOMER INFORMATION

**A Government Issued ID is Required

This section for business applicants only

LOCATION INFORMATION

RENTAL INFO

EMERGENCY CONTACT (Not living with you)

***IMPORTANT INFORMATION – PLEASE READ***

© 2020 Town of Shipshewana

FORMS

IMPORTANT INFORMATION – PLEASE READ