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2. 
4. Residential Service Request

   Application must be received & processed before 3 p.m. for same day service.

6. Date*
   Date

   Date
7. Please choose ONE of the following:*
   -- Select One --New ServiceDisconnectTransfer
9. Last Name*
10. First Name*
11. Middle Initial*
13. Service Address*
15. Service Address (to be discontinued if transferring services)
17. Date service to be connected:
    Date service to be connected:

    Required for ALL new or transferring service requests.

18. Date service to be disconnected:
    Date service to be disconnected:

    Required for ALL transferring or disconnecting service requests.

20. Is the service address same as billing address?*

    1. Yes
    2. No
21. If different from billing please include billing address.
23. Proof of ownership OR rental/lease agreement.*
24. Photo ID*
25. Account Number (from Utility Services)
27. Primary Phone*
28. Alternate Phone
29. Last 4 digits of SSN.*
31. Email Address
33. Service 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. The undersigned acknowledges that service is provided subject to adherence to the City of Crestview Terms and Conditions and services may be interrupted pursuant to any violation thereof. Undersigned also agrees to receive and pay for water, sewer and/or garbage service in accordance with the rates, rules and regulations until this service is formally discontinued.

    1. I agree to
34. Click to Review
    Terms & Conditions
36. Electronic Signature*
37. Date*
    Date
39. Electronic Signature

    Applicant #2 if applicable

40. Date
    Date
42. Deposit amount due upon approval of application.*

    1. Residential Deposit (inside city limits)
    2. Residential Deposit (outside city limits)

44. Please answer the following. Funding requirements for our USDA loans require that we collect ethnicity information to document nondiscrimination.

46. Race
47. Ethnicity

    1. Non-Hispanic
    2. Hispanic
48. Gender

    1. Female
    2. Male
50. Final bill information

    Please allow 3 to 4 weeks for the final bill to arrive.

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

* indicates a required field