If You Are the Property Owner

Utilities Service Application

Service Address:
Service Start Date:
Property Is: / Residential Commercial

IF YOU ARE THE PROPERTY OWNER

Name:
Mailing Address:
City: / State: / Zip:
Phone: / Cell Phone:
Driver’s Lic. #: / **Photo ID Required**
Email Address: / Required for Online Billing

IF YOU ARE THE TENANT

Name:
Mailing Address:
City: / State: / Zip:
Phone: / Cell Phone:
Email Address: / Required for Online Billing

NOTE: For rentals, both Property Owner and Tenant must fill out the above sections.

Garbage: / Residential: / Once Per Week Only / Size: / 20 Gal. Mini-Can 32 Gal. Can32 Gal. Cart ($1 Rental Fee)64 Gal. Cart ($1 Rental Fee)96 Gal. Cart ($1 Rental Fee)
Commercial: / Size: / 32 Gal. Can32 Gal. Cart ($1 Rental Fee)64 Gal. Cart ($1 Rental Fee)96 Gal. Cart ($1 Rental Fee)One Yard DumpsterOne and a Half Yard DumpsterTwo Yard DumpsterThree Yard DumpsterFour Yard DumpsterSix Yard DumpsterEight Yard Dumpster / #: / 123456 / Times Per Week: / 1235
Commercial: / Size: / None32 Gal. Can32 Gal. Cart ($1 Rental Fee)64 Gal. Cart ($1 Rental Fee)96 Gal. Cart ($1 Rental Fee)One Yard DumpsterOne and a Half Yard DumpsterTwo Yard DumpsterThree Yard DumpsterFour Yard DumpsterSix Yard DumpsterEight Yard Dumpster / #: / 0123456 / Times Per Week: / 01235

I affirm that all information on this application is true and correct. I will assume the full responsibility of all financial obligations at the above service address until I have notified the City in writing to discontinue service.

I hereby promise to pay all bills for services when due, and understand there are penalties on all unpaid balances, including discontinuation of service.

Signature of Owner or

Authorized Agent: ______Date: ______

Billing Options: Mailed Online Billing

Please print the completed form and return to City Hall located at S. 124 Lefevre St. or mail to the above address.

For Office Use Only / Meter Reading:
Photo ID Attached / Account Number:
Issued By: / Date: