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APPLICATION FOR UTILITIES SERVICE

2. 

4. All contracts for municipal utility service shall be signed in the true name of the customer(s) actually to receive and use such service. Any changes in the identity of the contracting customer at premises shall require a new application. The City may discontinue any municipal utility service until the City has accepted such new applications. Ordinance No. 2692 Sec. 700.080 Utility Service Application required.

6. APPLICANT(S):

8. ALL ADULTS LIVING AT THE SERVICE ADDRESS MUST BE INCLUDED ON THIS APPLICATION.

10. Name 1*

11. Social Security Number*

13. Date of Birth*

14. Employer*

16. Daytime Phone Number*

17. Email Address*

19. Name 2

20. Social Security Number

22. Date of Birth

23. Employer

25. Daytime Phone Number

27. Name 3

28. Social Security Number

30. Date of Birth

31. Employer

33. Daytime Phone Number

35. ALL ADULTS LIVING AT THE SERVICE ADDRESS MUST BE INCLUDED ON THIS APPLICATION.

39. FOR SERVICE AT:

41. Address*

42. Apartment Number (If applicable)

44. Landlord's Name*

46. Services Beginning On:*

48. Do you have access to a printer?*

    Check yes or no

    1. Yes
    2. No
50. Please include a high-resolution picture or scan of your drivers license

54. BILLING ADDRESS IF DIFFERENT FROM ABOVE:

56. Address

57. City/State

59. Zip Code

60. Phone Number

64. EMERGENCY CONTACT INFORMATION (Not someone living at the service address)

66. Relative's Name*

67. Relative's Phone Number*

69. Address*

70. City/State*

72. Zip Code*

Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field