Fill out this form to receive our senior citizen discount for customers 65 years and older.

Please fill the form out below or, if you prefer, print and complete this form and send to:

Mail: Austell Gas System, P.O. Box 685, Austell, GA 30168

Night Drop Box: 2838 Joe Jerkins Blvd, Austell, GA 30106

Fax: 770-948-8644

I am applying for the senior citizen discount offered by Austell Gas. I understand that the following is true and accurate:

1. I am sixty-five (65) years of age or older.
2. I live at the below address and the gas service account is in my name.

NOTE: The information provided is subject to audit and verification as deemed necessary by Austell Gas System. The applicant agrees to notify the company immediately if any change in the circumstances that make the applicant eligible for the discount.