If you agree to the policies in the policy section, you may print this form and bring it down to 23 Station Avenue, any weekday between 8:00 a.m. and 4:00 p.m.

PLEASE PRINT Name: ________________________________________________

Service Address: ____________________________________________________

Mailing Address: _____________________________________________________

Social Security #: _________________ Telephone: ________________________

Spouse's Name: _____________________ Social Security #:_________________

Your Employer's Name, _______________________________________________

Address, and Phone: _________________________________________________

Have you ever been a customer of the Department? Yes____ No ____

If yes, where: ________________________________ When_________________

Do you own the premises for which you have requested electric service: Yes____ No ___

If no, contact Barbara Cronin Customer Service Representative at 978-448-1150.

I have carefully read all the policies on the policy page of the Groton Electric Light Department web site and agree to be bound by the same as a part of my contract with the Department.

                   Signature: __________________________

                                   __________________________