Residential Applications, Add new

Residential Service Application
Service Information
Service Address				Mailing Address (if different from Service Address)
City		State	Zip	City	State	Zip
Start Date Enter requested start date of service				Secondary Customer Are you including a Secondary Customer contact? If yes complete Secondary Customer Section below.

Primary Customer Information				Secondary Customer Information (Optional)
Customer Name-Primary (Last Name, First Name Suffix)				Customer Name-Secondary (Last Name, First Name Suffix)
Social Security # --OR-- Driver's License # ID Type				Social Security # --OR-- Driver's License # ID Type
Phone Number 999-999-9999			Date of Birth MM/DD/YYYY	Phone Number 999-999-9999		Date of Birth MM/DD/YYYY
Email Address				Email Address
Employer				Employer
Previous Address				Previous Address (if different from Primary Previous Address)
City		State	Zip	City	State	Zip

Property Information
Owner	Non Owner	Property Owner Name (if different)		Landlord Name (if different)

Customer Comments

Customer Signature
The undersigned warrants that the information provided on this application is true, and is provided without intentional omission. My signature also acknowledges that I have read and understand the following Terms & Conditions.
Customer Signature			Date (MM/DD/YYYY)	Customer Signature		Date (MM/DD/YYYY)
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
TERMS & CONDITIONS
I understand that this is an application to establish/transfer utility service with Plymouth Utilities and that I am the responsible party. I understand that my service is subject to current rates, rules, and regulations as set in the tariffs that have been approved by the Public Service Commission of Wisconsin (PSC). I further understand that I am liable for all charges incurred until I provide notice to end utility services and that my final bill will be prepared within 15 days of termination. I understand that I am responsible to keep my contact information current and that any change to phone number, email address, or mailing address needs to be communicated to Plymouth Utilities. I understand that all information provided will be kept confidential. I understand that all information provided will be kept confidential in accordance with Wis. Stat. § 196.137. I understand that a deposit may be required.
The Utility agrees to return any deposits, with interest at the rate specified by the PSC unless: The residential customer did not provide 12 consecutive months of prompt payments The Customer’s service has been disconnected during this time for rule violation or nonpayment of a delinquent account. The Utility determines that information in the agreement was falsified or incomplete to the extent that deposit is required.
Form Type Service Application Property Type Residential Queue Review Submit Date 2/15/2026 Submit By Customer Trigger Add 1
* A confirmation email will be sent to the addess specified on the application *

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