WATCH CARE
www.watchcare08@yahoo.com
Utility Assistance Application
You need Java to see this applet.
FULL NAME
REFERRED BY
ADDRESS
CITY, ZIP CODE
EMAIL ADDRESS
HOME PHONE
CELL PHONE
WORK PHONE
YOUR AGE
EMPLOYMENT INFORMATION
EMPLOYER
EMPLOYERS PHONE #
NUMBER OF
YEARS
EMPLOYED
EMPLOYERS ADDRESS
EMPLOYERS CITY
OCCUPATION
HOW WOULD YOU LIKE TO RECEIVE BILLS?
HOW OFTEN PAID?
U S Mail
Email
Fax
Other
Weekly
Bi-Weekly
Twice a Month
Monthly
Other
UTILITY SERVICE INFORMATION
SERVICE ADDRESS
APT/FLR
CITY
IS THIS YOUR
BILLING ADDRESS?
YES
NO
IF NO, PROVIDE BILLING ADDRESS:
SERVICE ADDRESS # 2
(IF APPLICABLE)
APT/FLR
CITY
SELECT SERVICES DESIRED
Please check below
NICOR GAS
PEOPLE'S GAS
COM-ED
ENTER AMOUNT PAST DUE
ENTER AMOUNT PAST DUE
ENTER AMOUNT PAST DUE
IS YOUR GAS OFF?
WHERE
DISCONNECTED
FROM?
ELECTRICITY OFF?
WHERE DISCONNECTED FROM?
NO
YES
NO
YES
METER
POLE
METER
STREET
HOW LONG GAS
DISCONNECTED?
HOW LONG ELECTRIC
DISCONNECTED?
GAS
ACCOUNT
NUMBER
ELECTRIC
ACCOUNT
NUMBER
COMMENTS OR
REMARKS
WHAT MEASURES HAVE YOU TAKEN TO
RESTORE SERVICE? (EXPLAIN)
PLEASE SUBMIT APPLICATION AND WE WILL EMAIL YOU CONFIRMATION.
IF YOU DO NOT RECEIVE CONFIRMATION WITHIN 24 HOURS, PLEASE TELEPHONE US AT
(847) 770-8330.