Fillable . CentralHudsonrequestsyoucompleteSectionsIVaccuratelysothatwemayplaceyouraccountontheproperserviceclassification.Sincedifferenteligibilityrequirements andratesforthevarious serviceclassificationsexis

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. CentralHudsonrequestsyoucompleteSectionsIVaccuratelysothatwemayplaceyouraccountontheproperserviceclassification.Sincedifferenteligibilityrequirements andratesforthevarious serviceclassificationsexist,theinformationyouprovidebelowwillassisttheCompanyinclassifyingyouraccountintheappropriateserviceclassificationandratewhichismostbeneficialtoyou. Yourloadcharacteristicsandnatureofbusinessdetermineyoureligibilityforvariousrateswithinaserviceclassification.Shouldtherebeachangeinusageorequipmentatafuturedate,youmust notifyCentralHudsoninordertoassurethatyouareproperlybilled.IfthisapplicationisforaReligiousOrganization,CommunityResidenceorVeteransOrganizationandCentralHudsondenies youresidentialrates,youmaysubmitarequestinwritingthatCentralHudsoninspectthepremiseandreviewtheratebasedontheresultsofthisfieldinspection.Youmayalsoappealtherate classificationtothePublicServiceCommission.Iftheinformationprovidedbyyouisinaccurateorincomplete,youmaybesubjecttobackbillingonthecorrectserviceclassificationormaynot

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FormNo.015/Rev.10/17 Page1



SectionI:Account/CommercialDetails(PleasePrintandCompleteAllSections)

NameonAccount:_________________________________________________________

ServiceAddress

:___________________________________________________________



StreetCityZip

MailingAddress:___________________________________________________________



StreetCityZip

Telephone:__________________________________Email:_________________________

OwnerNameorParentCompany:_____________________________________________

 Corporation ___D/B/A Partnership LLC

NatureofBusiness(i.e.Accountingfirm,Hardwarestore,Restaurant,etc.):

_______________________________________________________________________

SSN/EIN#_____________________________StateofOrganization________

PresentorPreviousServiceInformation:

DateofLastService(Month/Year):__________________ 

UtilityCompany(ifotherthanCentralHudson):_______________________________________

AddressofLastService:



___________________________________________________________



StreetCityZip

____NoPresentorPreviousService



SectionII:AuthorizedSigners (PleasePrint)

SignerI:

Name:_________________________________________________

 FirstName  LastName

Title:________________________________________

Address:_________________________________________________



Street   City  Zip

Phone#:___________________________

SocialSecurity#:_____________________

Driver’sLicense#:__________________State:____Exp:________

Signature:_____________________________________________

SignerII:

Name:_____________________________________________

 FirstName  LastName

Title:________________________________________

Address:_________________________________________________



Street   City  Zip

Phone#:___________________________

SocialSecurity#:_____________________

Driver’sLicense#:__________________State:____Exp:________

Signature:_____________________________________________

CentralHudsonrequestsyoucompleteSectionsI‐Vaccuratelysothatwemayplaceyouraccountontheproperserviceclassification.Sincedifferenteligibilityrequirements andratesforthevarious

serviceclassificationsexist,theinformationyouprovidebelowwillassisttheCompanyinclassifyingyouraccountintheappropriateserviceclassificationandratewhichismostbeneficialtoyou.

Yourloadcharacteristicsandnatureofbusinessdetermineyoureligibilityforvariousrateswithinaserviceclassification.Shouldtherebeachangeinusageorequipmentatafuturedate,youmust

notifyCentralHudsoninordertoassurethatyouareproperlybilled.IfthisapplicationisforaReligiousOrganization,CommunityResidenceorVeterans’OrganizationandCentralHudsondenies

youresidentialrates,youmaysubmitarequestinwritingthatCentralHudsoninspectthepremiseandreviewtheratebasedontheresultsofthisfieldinspection.Youmayalsoappealtherate

classificationtothePublicServiceCommission.Iftheinformationprovidedbyyouisinaccurateorincomplete,youmaybesubjecttobackbillingonthecorrectserviceclassificationormaynot

receivearefundforoverchargesbasedontheimproperserviceclassification.Representativesareavailabletoassistyouwithanyquestionsorconcernsyoumayhaveregardingservice

classification.ClickheretoseeyourBusinessCustomerRights.Acopyofourtariff,whichdescribeseachserviceclassificationindetail,isavailableonourwebsiteatCentralHudson.com

.

      Page2



SectionIV:

(Checktheappropriatebox)



SectionIII:LoadDetails

(PleasePrint)

ElectricConnectedLoad

LOAD   10  30

Motor#_______________  __________HP ________HP

Lighting    __________KW ________KW

Heating    __________KW ________KW

A/C#_________________  __________KW ________KW

Refrigeration   __________KW ________KW

Other_________________ __________KW ________KW

GasConnectedLoad

LOAD   

Heating    __________BTU 

AllOtherAppliances  __________BTU

AccessController

 

Name____________________________________________________

 

First  Last

Address:__________________________________________________



Street   City  Zip

Phone#

SectionV:



PrintName:_________________________________________ Company/Representative:__________________________________________________________

Signature:_____________________________________________ Date:_______________________

 

First  Last

SectionVI(OfficeUseOnly‐LeaveBlank):



Application#:_________________________________________ SICCode:____________________ DepositAmount:______________________

Account#:_____________________________________________ DateofUnlock:___________________

Comments:__________________________________________________________________________________________

Fillable . CentralHudsonrequestsyoucompleteSectionsIVaccuratelysothatwemayplaceyouraccountontheproperserviceclassification.Sincedifferenteligibilityrequirements andratesforthevarious serviceclassificationsexis

Fill Online, Printable, Fillable, Blank . CentralHudsonrequestsyoucompleteSectionsIVaccuratelysothatwemayplaceyouraccountontheproperserviceclassification.Sincedifferenteligibilityrequirements andratesforthevarious serviceclassificationsexis Form

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