Shallotte Customer Portal
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Utility Service Application
Utility Service Application
Applicant Information
Check here if you are currently a customer of at another address:
Current Account:
*
Create Cut-off Service Order for Current Account?
Requested Turn Off Date:
*
Requested Turn Off Time:
*
×
Social Security Number
Enter last 4 digits of SSN:
*
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:
Remove Co-Applicant
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 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, I acknowledge that this is my electronic signature and that I hereby consent to the electronic submittal of the service application to Town of Shallotte through which I am requesting sewer service at the address listed therein. I am confirming that I have read and agree to the Terms of Service and Service Agreement, found on Town of Shallotte’s website www. townofshallotte.org, and that all information that I have provided is accurate. Through my initials above, I do hereby agree to these terms of service and understand that my failure to comply with such terms may result in the disconnection of sewer and/or water service. I understand that if I have a sewer issue, I can contact the Town Hall at (910) 754-4032 Monday through Friday (8am to 5pm). If I have a sewer issue after these hours, I can contact the after-hours technician at (910) 233-5693. FOR THE APPLICATION TO BE PROCESSED PLEASE VERIFY THE BELOW ITEMS ARE SUBMITTED. * SOCIAL SECURITY NUMBER OF APPLICANT **** 2 TYPES OF IDENTITY DOCUMENTS***** (DL PREFERRED) * FULL PAYMENT OF ANY PAST DUE ACCOUNTS FOR APPLICANT(S)
Initials:
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
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