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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.