Municipal Gas Application for Service

Complete online or print and fill out by hand.

This application includes a Social Security Number field required for utility service verification. Nothing entered here is transmitted or saved online — please print the completed form and deliver it to City Hall in person or by mail, along with a voided check if signing up for automatic withdrawal.

Lenox Municipal Gas Application for Service

Applicant Information

Name

Social Security Number

Only entered on the printed copy you deliver in person — never transmitted online.

Date of Birth

Service Address

Billing Address (if different from service address)

Email

Billing Preference

Email Bill Print/Mail Bill

Phone Number

Employment Name/Telephone Number

Automatic Withdrawal Sign me up for automatic withdrawal from my checking (must include a voided check with application)

Services Requested

I hereby apply for the following services for the service address listed above, pursuant to the conditions below:

Gas Garbage

Conditions of Service

I agree to pay a deposit of $200.00 prior to service connection for gas service.
I agree to pay all bills rendered by Lenox Gas System for services provided beginning Service start date to the date service is discontinued.
I agree to give notice to Lenox Gas System of my intent to discontinue service.
I hereby verify that I have no outstanding bills with the Lenox Gas System under my current name or any other name I have used in the past, or under a current or former spouse's name.
I have received the New Customer Package provided by the Lenox Gas System.
If you have automatic withdrawal checked, you are agreeing to allow Lenox Gas System to debit your account for the amount of your bill.

Signatures

Applicant Signature If printing to sign by hand, you may leave this field blank.

Lenox Gas System Representative Signature

Completed by Lenox Gas System staff.

Date

This form is not submitted online. Please print and deliver the completed application to Lenox City Hall in person or by mail — this protects your Social Security Number and other sensitive information from being transmitted electronically.