Account Information
Service Address*
Street Address (Include apartment or suite number) City State ZIP Code
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Mailing Address*
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Customer Information
Account Type*
Business Name*
Contact Person*
First Last
Primary Customer Name*
First Last
Date of Birth*
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
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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