2. 
4. Notices:
   Service will not be rendered unless application information is complete.
   
   The City of Port Arthur will not be responsible for any damage incurred because of leaks or open faucets at the time service is turned on at your meter.
6. Applicant's Information:
8. First Name*
9. Last Name*
10. Phone Number*
12. Service Address*
14. City*
15. State*
16. Zip Code*
18. Email Address
20. Mailing Address*
22. City*
23. State*
24. Zip Code*
26. Employer
27. Business Phone Number
29. Last 4 Digits-Social Security Number*
30. Driver's License*
    -- Select One --YesNo

    Do you have a valid Driver's License?
32. Landlord Information
34. Landlord Name
36. Address
38. City
39. State
40. Zip Code
42. Landlord's Email Address
44. Co-Applicant's Information
46. First Name
47. Last Name
49. Employer
50. Business Phone Number
52. Date of Birth
53. Last 4 Digits-Social Security Number
55. Additional Contact Information
    Please provide contact information of relative not living with you.
57. Relative's Name
58. Relationship
59. Phone Number
61. Address
63. City
64. State
65. Zip Code
67. Please read the following information carefully.
    1. All charges and bills not paid by the due date will be past due and a late charge of 10% will be added to the past due amount.
    2. Unpaid bills become delinquent 10 days after the due date; a DELINQUENT NOTICE will appear in red on your billing statement.
    3. Service will be discontinued on all delinquent accounts and not restored until all delinquent amounts are paid in full or other acceptable payment arrangements are made.
    4. A $25.00 reconnection fee will be assessed on all accounts turned off for non-payment or waste; $35.00 after 3 P.M.
    5. Failure of the consumer to receive any bill or delinquency notice shall in no way relieve the consumer of the necessity of paying nor shall it protect the consumer from discontinuance of service. Consumers may request a hearing with the Utilities Office Manager.
    6. Adjustments shall only be made under the following circumstances and conditions in the event of an unusually high consumption for known reasons or leaks documented by the consumer. No adjustment or refund will be made for any error in billing unless such error is called to the attention of the Water Department in writing on forms prepared by the department with six months of the date of the billing. Adjustments are limited to the difference between the amount of sewer charged on the bill in question and the consumer's average sewer bill over the previous 3 to six months.
    7. All properties connected to the water/sewer system shall be assumed to be using such services. The consumer and the property owner will be held equally responsible for all charges incurred until a written notice of termination is given to the City Water Department.
69. Affirmation
    Everything that I/we have stated in this application is correct and true to the best of my/our knowledge.
    You are authorized to check my/our credit and employment history and to answer questions about your credit experience with me/us. I/we have read the above contract and agree to all its terms and conditions.
71. Signature of Applicant*
72. Date
74. Signature of Co-Applicant
75. Date
77. New Service: Previous History*
    -- Select One --YesNo

    Have you ever had service with us before?
78. If Yes, please provide All service locations:
80. New Service Application : Required Documents
    In order to establish service with us, you must have:
    
    1. A valid driver's license. Please upload a copy below.
    2. A Mortgage or Lease Agreement. Please upload a copy below.
    
    The name on the mortgage, or deed, must match the name on the Driver's License
82. Upload a copy of your Driver's License
83. Upload a copy of Your Mortgage or Deed
85. Verification
    Information that I/we have provided in this statement is correct and true to the best of my/our knowledge. You are authorized to check credit and employment history and to answer questions about your credit experience with me/us. By signing, I understand that any balances owed by myself or co-applicant at any previous addresses provided or any other previous addresses found by the Utilities Operations Department using my Social Security number and name, shall become payable before service is established at the address requested.
    
    By signing, I understand that I release Entergy to provide to the City of Port Arthur Customer Service Representative with Entergy Account Information, which shall include, but not be limited to, name on account, Social Security number, service address, and I release the City of Port Arthur to provide same said information to Entergy upon request.
87. Signature of Applicant*
88. Date
90. Signature of Co-Applicant
91. Date
95. Customer Service Representative
    This section reserved for City of Port Arthur Customer Service Representative. Do not fill out this section.
Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit Submit and Print

* indicates a required field