Sign Up For New Service

Welcome to Jefferson! We're happy to be your new utility provider. For your convenience, you may fill out the below information to sign up for service. If you prefer to submit a paper form, you can visit our office at 425 Collins Road, Ste A, Monday through Friday, 7:30 a.m. to 4:30 p.m. If you have any questions or concerns, please contact our office at 920.674.7711.

Rent or Own *

Rent

Own

Date of New Service *

New Address

Street Address *

Apt.

City *

State *

Zip *

Mailing Address

Street Address *

Apt.

City *

State *

Zip *

Applicant #1 Information

Applicant #1 First Name *

Middle Initial

Last Name *

Date of Birth *

Primary Phone *

Secondary Phone

Applicant #1 Identification

You must enter one of the following ID numbers or your application will be rejected.

Driver's License/State ID Number

Passport Number

Applicant #2 Information

Applicant #2 First Name

Middle Initial

Last Name

Date of Birth

Primary Phone

Secondary Phone

Applicant #2 Identification

If providing a second applicant information, you must enter one of the following ID numbers or your application will be rejected.

Driver's License/State ID Number

Passport Number

Previous Address

Street Address

Apt.

Landlord Information

New Landlord Name

New Landlord Phone Number

Primary Phone

Secondary Phone

Leave this field blank

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Search form

New Address

Mailing Address

Applicant #1 Information

Applicant #1 Identification

Applicant #2 Information

Applicant #2 Identification

Previous Address

Landlord Information