HHRWD | Forms | New Customer Information

Forms

New Customer Information New Service Application ACH Form Users Agreement

To setup service as a New Customer please fill out the New Customer Information form and the User's Agreement. Also, scan and send a copy of your driver's license. Call with Debit/Credit Card to pay deposit.

To setup a NEW service, meaning if you need a new meter set; please fill out the New Service Application and the User's Agreement and send copy of your driver's license. Call with Debit/Credit Card to pay fees.

If you have questions about forms please call the office at 812-654-3200. If forms are not filled out entirely, service will not be connected.

New Customer Information

Click Here to fill out and Download the Form.

* indicates a required field

To be completed by applicants - Please complete all sections.

* Client's First Name: * Client's First Name:

* Client's Last Name: * Client's Last Name:

* Birth Date: * Birth Date:

* Phone: * Phone

Mobile: Mobile

* Driver's License Number: * Driver's License Number:

* Bill:

Email: Email

Billing Address

* Street: * Street:

* City: * City:

* State:

* Zip: * Zip:

Service Address

* Street: * Street:

* City: * City:

* State:

* Zip: * Zip:

To be completed by office

Location Book: Location Book:

Account: Account:

COMMENTS: COMMENTS