NEW SERVICE APPLICATION

Thank you for selecting BPUB as your service provider! Please fill out the form below and submit.

A BPUB Customer Service Representative will call to confirm your application and verify your information. Once confirmed, please visit our offices on 1425 Robinhood Drive to complete the application process. A representative will confirm your date for either opening a new account, connecting a new service or disconnecting your current service.


Request Date:
DEPOSIT $50.00 / SERVICE FEE $25.00 FOR EA. SERVICE

1.
  APPLICANT'S FULL NAME (FIRST, MIDDLE, LAST, TITLE)
 
2.
  SOCIAL SECURITY AND VALID DRIVERS LICENSE OR I.D. NUMBER
 
3.
  SERVICE ADDRESS
 
4.
MAILING ADDRESS
 
5.
UTILITY COMPANY SERVING PREVIOUS ADDRESS
 
6.
HOME PHONE NUMBER OR CELLULAR
 
7.
  PLACE OF EMPLOYMENT
 
8.
NAME OF RELATIVE OR REFERENCE--WHO TO CONTACT IN AN EMERGENCY.
EXAMPLE: IF WE NEED TO DISCONNECT SERVICE FOR A PERIOD OF TIME AND NO ONE IS HOME OR
IN CASE OF FIRE.
 
9.
NAME AND TELEPHONE NUMBER OF LANDLORD IF RENTING
 
10.
  OTHER
 
IF APPLICABLE
 
1.
  SPOUSE'S FULL NAME
 
2.
  PLACE OF EMPLOYMENT
 
3
  SOCIAL SECURITY AND DRIVERS LICENSE
 


By clicking on Submit you agree that you must pay the deposit & service charge within
24 hours or services will not be connected.


 Please read Terms and Conditions & Texas State Sales and Use Tax before submitting any forms.