CITY OF
Request fo=
r Utilities
New Account No.: ___________________ Date To Be Turned On: _____/_____/_____
Name: __________________________________ Date of Birth: _____/_____/_____
Property Address:&nbs= p; ______________________________________________________
Billing Address: ________________________________________________________
City / State / Zip:&n= bsp; _______________________________________________________
Employer: __________________________ Employer Phone No.: _______________
Home Phone No.: ____________________ Cell Phone No.: ____________________
SS #:
______________________ DL #:
Customer Signature:&n= bsp; _____________________________________________________
Reviewed by Employee:= _____________
…………………̷= 0;…………………………= 230;…………………………&= #8230;……………...
**Office Use O=
nly
Type of Service: Residential or Commercial = Water / Sewer = Pool
Size Line: _________________________
Deposit Amount: $_______________ Date Deposit Paid _____/_____/_____
Checked for Previous Balance ________________
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Employee initials
***Attach rec=
eipt(s)
to form.
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30;…………………………&#=
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……
Termination Request <= /span> &nbs= p; &= nbsp; Termination Date: _____/_____/_____
Forwarding Address:&n= bsp; ______________________________________________________
______________________________________________________= __________________
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City =
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Customer Signature________________________________________________________