Account Information
Service Address*
Street Address (Include apartment or suite number) City State ZIP Code
Is your mailing address different than your service address listed above?*
- Yes
- No
Mailing Address*
Street Address (Include apartment or suite number) City State ZIP Code
Customer Information
Account Type*
Business Name*
Contact Person*
First Last
Primary Customer Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Driver License Number
State of Issuance for License
State
Social Security Number*
Last 4 digits only
Business License Number*
Federal Tax ID Number*
Secondary Customer Name
First Last
Secondary Customer Date of Birth
Date Format: MM slash DD slash YYYY
Secondary Customer License Number
State of Issuance for License
State
Secondary Customer Social Security Number
Last 4 digits only
Primary Phone*
Secondary Phone
Email Address
Lewis County PUD Account Number
Questions/Comments
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Name
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