General Primary Account Holder InformationPlease select one of the following:* I am buying this home I am renting this home or apartment I am renting out a home that I own I am managing this home/apartment for the owner I am requesting utility service at the indicated location. By completing this form I agree to be financially responsible for the cost of all utility services provided by Clark Public Utilities at this location until the account is closed.I am requesting utility service on behalf of my tenant. By completing this form, I certify that I am authorized to initiate this account, have verified the identity of my tenant, and that I currently have a rental agreement in place. I understand that if I sign up for utility service on behalf of another person, without authorization or verifying their identity, I may be personally responsible for this account.Name of person filling out this form on behalf of tenant:* First Last Name on Utility Account:* First Last Phone Number:*Email Address:* Social Security Number:* Why do you need my SSN? Social Security numbers are required to start electric service and this website is encrypted and secure. If you do not have a social security number, please contact Customer Service at 360-992-3000 before submitting your form and a representative will help you determine next steps.Date of Birth:* MM slash DD slash YYYY Employer: Work Phone:Service AddressService Address:* Street Address Address 2 (Unit/Apt/Suite #) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date you want service started:* MM slash DD slash YYYY Mailing AddressIs your mailing address different than your service address?* Yes No Mailing Address:* Street Address Address 2 (Unit/Apt/Suite #) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Co-occupant InformationWould you like to add additional household members to the account?* Yes No Is the household member a spouse? Yes No Co-occupant's Name:* First Last Spouse's Name:* First Last Co-occupant's Social Security Number:* Why do you need my SSN? Social Security numbers are required to start electric service and this website is encrypted and secure. If you do not have a social security number, please contact Customer Service at 360-992-3000 before submitting your form and a representative will help you determine next steps.Spouse's Social Security Number:* Why do you need my SSN? Social Security numbers are required to start electric service and this website is encrypted and secure. If you do not have a social security number, please contact Customer Service at 360-992-3000 before submitting your form and a representative will help you determine next steps.Co-occupant's Date of Birth:* MM slash DD slash YYYY Spouse's Date of Birth:* MM slash DD slash YYYY Co-occupant's Employer: Spouse's Employer: Co-occupant's Work Phone:Spouse's Work Phone:Would you Like to add an additional co-occupant? Yes No Additional Co-occupant InformationSecond Co-occupant's Name:* First Last Second Co-occupant's Social Security Number:* Why do you need my SSN? Social Security numbers are required to start electric service and this website is encrypted and secure. If you do not have a social security number, please contact Customer Service at 360-992-3000 before submitting your form and a representative will help you determine next steps.Second Co-occupant's Date of Birth:* MM slash DD slash YYYY Second Co-occupant's Employer: Second Co-occupant's Work Phone:Additional InformationAny additional information you wish to provide:
