NEW CUSTOMER REQUEST     

                                                    CUSTOMER DATA CHANGE

Town of Derry, NH

14 Manning Street 

Derry, NH 03038                                 

 

Please Print                                          Once completed, please return to:  Tax Collector

Existing  Customer   Number:

 

Date:

Owner(s)

Last Name:

 

First:

 

 

 

DBA:

 

Property Address:

 

Mailing Address:

 

PO Box:

 

City State Zip

 

Map & Lot: (if applicable)

 

Resident?

 

Telephone:

 

Additional Addresses for

Tax, Utility, General Billing* (specify module)

 

 

Tenant Name:

 

Business Data:

 

 

Federal Tax ID#

Fax #

Contact Name:

 

Individual/Sole Proprietor

 

Corporation

 

Partnership

 

Special Conditions-

Please list:

(specify dates)

 

 

 

 

Signature: ___________________________ Requested by: _______________________

                                                                       

Department:    _______________________

 

*Additional bills for utility service can be sent to tenants upon request in writing.

 

 

 

  For Tax Collector office use only:

Customer number assigned:

 

Existing customer number:

 

Completed by:

 

Date: