Commercial Utility Service Request Form

April 27, 2016

Name of business * Required
Name * Required
First Last
Have you had service with the city before? * Required
- Yes
- No
Account name
First Last
(If you have had service with the city before)
Last service address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

(If you have had service with the city before)
New service address * Required
Street Address Address Line 2 City State ZIP Code

Where water, sewer and trash service will be.
Request turn on Date * Required
MM slash DD slash YYYY
Request turn on time * Required

: Hours

Minutes

AM/PM AM/PM
Trash service request * Required
- Polycart
- Polycart plus extra polycart
- Dumpster - 3 yard 1 time pick-up
- Dumpster - 3 yard 2 time pick-up
Billing address * Required
Street Address Address Line 2 City State ZIP Code

Where you would like your bill sent to.
Email

Where you would like your bill sent to.
Phone * Required
If the city needed to get a hold of you in case of leak detection or other matters.
Alternate phone
Social Security Number * Required
Driver's license number * Required
I would like my personal information to be kept confidential, in accordance with state law * Required
- Yes
- No

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