CHESAPEAKE HOME > CUSTOMER INFORMATION > APPLICATION FOR SERVICE


Use this form if you:

  • want gas service turned on
  • want gas service turned on and turned off at your old address
  • If you would rather phone in this information, feel free to call your local office

To process your request, we will have to call you back to verify information and to schedule an appointment.

A deposit may be required before establishing service.

To make this process easier for you, we request that you not leave any spaces blank, as all information is required before your application can be processed.

Customer Name:
E-mail address:
Marital Status:
single married
Will there be a co-customer on this account?
yes no
Type of service requested:
turn on new service
turn on new service and turn off old service
Gas appliances in residence:
furnace
cooktop
barbecue

water heater
fireplace
gas light

 range
dryer
pool heater

New Address Information
New service address:
City:
 State:
 Zip:
County:
Is the mailing address the same as above?
yes no
Date you wish service to start:
Number of people living at this service address:
Do you own or rent this residence? Own Rent
 

Customer Information

Customer's employer:
Employer's phone
Area
code:
 Number:
 Position:
Number of years with this employer:
Active Military?
yes no
Photo ID or Driver's
License Number:
 State
Issued:
 Date of Birth:
New phone
Area
code:
 Number:
 Area
code:
Location of message phone:
Current address:
City:
 State:
 Zip:
County:
Area
code:
 Phone Number:
Length of time at this address:
Date you wish service
to end at this address:

We cannot complete this request until we reach you by telephone to schedule an appointment to turn on your service. Our service technician will need access to the inside and outside of your home.

Please tell us the best time to call and arrange a weekday appointment.

morning

 afternoon
Area
code:
 Number:
 Ext:

I understand and agree that I am responsible for payment of all Utility services incurred including deposit amounts.

PLEASE NOTE: The above data will be transmitted via an unsecured server. If you are not comfortable in submitting information using this method, please call your local Chesapeake Utilities office to apply by phone.


Please make sure all fields are complete and correct before submitting your application. Thank you.



Copyright©1998, All Rights Reserved
webmaster@chpkgas.com