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New Residential Service Application

  1. My Post Copy (4)

  2. RESIDENTIAL UTILITY SERVICE AGREEMENT

  3. Do You:

  4. Do you have an irrigation system?

  5. Do you have pets that bite or display signs of aggression?

  6. If pets are aggressive, is it an outside dog?

  7. PRIMARY ACCOUNT HOLDER

  8. Preferred Contact Method

  9. SECONDARY ACCOUNT HOLDER

  10. EMERGENCY CONTACT

  11. WASTEWATER SERVICE OPTIONS

    Choose the following option that you prefer for your summer sewer rate:

  12. PRIVACY INFORMATION

  13. Type full name here for signature

  14. For YES, please type full name here for signature

  15. AGREEMENT SIGNATURE

  16. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. I/We agree to abide by the Republic City Ordinances/Regulations pertaining to utility services; that all the above information is true and accurate; and that I/We are responsible for all billings until written notification is provided to the City to discontinue service.

  17. Leave This Blank:

  18. This field is not part of the form submission.