Form Center

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
52. Please include a copy of the first page of your lease or a copy of your closing papers*
56. BILLING ADDRESS IF DIFFERENT FROM ABOVE:
58. Address
59. City/State
61. Zip Code
62. Phone Number
66. EMERGENCY CONTACT INFORMATION (Not someone living at the service address)
68. Relative's Name*
69. Relative's Phone Number*
71. Address*
72. City/State*
74. Zip Code*
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field