Utility Service Application

Applicant Information

Check here if you are currently a customer of Parker County SUD at another address:

Current Account: *

Create Cut-off Service Order for Current Account?

Requested Turn Off Date: *

Requested Turn Off Time: *

Please indicate type of account:Residential: Business:

Business Name: *

First Name: *

Middle Name:

Last Name: *

Date of Birth: *

Home Phone: *

Mobile Phone: *

Federal ID: *

Work Phone: *

Email: *

Driver's License: *

SSN: *

Gender:

Ethnicity:

Race:

Name:

Home Phone:

Mobile Phone:

Work Phone:

Email: *

Date of Birth: *

Driver's License:

SSN:

Relationship:

Please enter the address for which you are requesting service.

Address: *

City: *

State: *

Zip Code: *

Check if you own this residence:

Name of mortgage company: Name of landlord:

Check if your billing address is same as the service address:

If not, please enter your billing address

Address: *

State: *

City: *

Zip Code: *

Address:

City:

State:

Zip Code:

Requested Turn on Date for Utilities: *

Requested Turn on Time for Utilities: *

Name: *

Phone No: *

Address:

City:

State:

Zip Code:

Additional Comments:

Please attach required documents here:

Drag file here

Current Image:

Check here if you are currently a customer of Parker County SUD at another address:

Current Account:

Create Cut-off Service Order for Current Account

Requested Turn Off Date:

Requested Turn Off Time:

Type of account:

First Name:

Middle Name:

Last Name:

Business Name:

Date of Birth:

Home Phone:

Mobile Phone:

Work Phone:

Email:

Driver's License:

SSN:

Federal ID:

Co-Applicant Information:

Name:

Home Phone:

Mobile Phone:

Work Phone:

Email:

Date of Birth:

Driver's License:

SSN:

Relationship:

Service Address:

Address:

State:

City:

Zip Code:

Check if you own this residence:

Name of mortgage company: Name of landlord:

Check if your billing address is same as the service address:

If not, please enter your billing address

Address:

State:

City:

Zip Code:

Previous Address:

Address:

State:

City:

Zip Code:

Requested Turn on Date for Utilities:

Requested Turn on Time for Utilities:

Name:

Address:

State:

Phone No:

City:

Zip Code:

Additional Comments:

By clicking Submit, you agree to abide by the established Rules and Regulations currently in force, and pay for service prior to the due date or be subject to disconnections for non-payment. Submission also confirms that the applicant is over 18 years of age, and that all information provided by them is accurate.

Your application has been submitted. You will receive a notification whether it has been denied or approved once it has been processed and completed.

Your application number is