Melrose Public Utilities 225 1st St NE, Melrose, MN Service & Credit Application

Tennessen Warning for Utility Service and Credit Application

As a potential customer of the Melrose Public Utilities, you are being asked to provide information about yourself for billing and/or credit information. The information to be exchanged will be treated as private as governed by Minnesota Statute Section 13.01-13.90 and The Privacy Act of 1974.

The information will also be used for collection purposes in case of nonpayment of utility bills.

The data will be used solely for the above-mentioned purposes. The data will be forwarded to the appropriate city/utility staff whose work assignment reasonably requires access to the information for billing and collections.

You are not legally required to provide the requested information. However, if you do not provide the required information we may refuse to provide electric, water and wastewater (utilities) services.

By signing this form, you hereby acknowledge that you have requested the Melrose Public Utilities to provide you with utilities services. You further agree to be responsible for all charges incurred with the utility, including interest and/or penalties. You agree to pay said account regardless of how dated the account is and absolve the utility from continuing to provide service after a delinquency and/or after the normal cut-off date.

By signing this form, the applicant is representing to the utility that he/she has the legal right to occupy the premises. Proof of legal right to occupy the premises maybe required. By signing this form, the applicant hereby waives their rights to any claims and hereby agrees to hold harmless Melrose Public Utilities and the City of Melrose, Minnesota and any of its agents or employees for any injury of damage which may be experienced as a direct or indirect results of the intended use of this information.