Section 1: Contact OR Customer Information - ALL requests answer this section.

1. Are You the Customer? ALL Utility requests answer this question. Select from Menu Yes No *
2. Request Pertains To Select from Menu Electric Gas Water Sewer Telephone Cable Landfill Trash Hauler Taxi/Limousine Wrecker Moving/Storage Commercial Recycler Compost Facility Railroad Weight Enforcement Safety Enforcement Coal Hazmat Motor Carrier *
3. Email Address - *
4. First Name *
5. Last Name *
6. Business name - if available.
7. Address 1 *
8. Address 2
9. City *
10. County   Barbour Berkeley Boone Braxton Brooke Cabell Calhoun Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Jefferson Kanawha Lewis Lincoln Logan Marion Marshall Mason McDowell Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas Ohio Pendleton Pleasants Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood Wyoming *
11. State   Alberta Alaska Alabama Arkansas Arizona British Columbia California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Manitoba Maryland Maine Michigan Minnesota Missouri Mississippi Montana New Brunswick North Carolina North Dakota Nebraska New Hampshire New Jersey Newfoundland and Labrador New Mexico Nova Scotia Northwest Territories Nunavut Nevada New York Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island South Carolina South Dakota Saskatchewan Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Yukon *
12. Zip *
13. If no phone, please fill out Section 2 BELOW.
14. Home Phone **Please include area code. Example: xxx-xxx-xxxx ** *
15. Business/Work Phone
16. Alternate Phone

Section 2: Contact Person, if OTHER than ABOVE

1. First Name
2. Last Name
3. Address 1
4. Address 2
5. City
6. State   Alberta Alaska Alabama Arkansas Arizona British Columbia California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Manitoba Maryland Maine Michigan Minnesota Missouri Mississippi Montana New Brunswick North Carolina North Dakota Nebraska New Hampshire New Jersey Newfoundland and Labrador New Mexico Nova Scotia Northwest Territories Nunavut Nevada New York Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island South Carolina South Dakota Saskatchewan Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Yukon
7. Zip
8. Home Phone **Please include area code. Example: xxx-xxx-xxxx **
9. Business/Work Phone
10. Alternate Phone
11. Relation to Customer Select from Menu Mother Father Son Daughter Sister Brother Grandparent Friend Spouse Roommate Social Worker Other
12. If OTHER, please state relationship -

Section 3: Utility Information

1. Is this request associated with a specific account? Select from Menu Yes No *
2. You MUST answer the questions BELOW, if the above answer is YES OR if the UTILITY TYPE is Electric, Gas, Sewer, Water, Telephone or Cable.
3. Type of Service Select from Menu Residential Business *
4. Name of Utility Company *
5. Your Account Number *
6. Did you contact the utility? "> Select from Menu Yes No *
7. Name of person at utility that you spoke with *
8. Date *

Section 4: Briefly Describe Situation and Remedy Being Requested - ALL requests answer this section. *