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2. 
4. Temporary Water Service Application
6. Application Must Be Received and Processed Before 3 p.m. for Same Day Service
8. Date*
   Date

   Date
10. Last Name*
11. First Name*
12. Middle Initial*
14. Service Address*
16. City*
17. State*
18. Zip Code*
20. Proof of Ownership or right of admittance to property*
21. Is service address different from billing address*

    1. Yes
    2. No
23. Billing Address
25. City
26. State
27. Zip Code
29. Primary Phone*
30. Alternate Phone
32. Last four (4) digits of Social Security Number*
33. Valid Photo ID
34. Email Address
36. Date Service to be Connected/Disconnected (Services unavailable on weekends and holidays.)*
    Date Service to be Connected/Disconnected (Services unavailable on weekends and holidays.) Start Date

    —

    Date Service to be Connected/Disconnected (Services unavailable on weekends and holidays.) End Date
    TEMPORARY WATER IS FOR 10 BUSINESS DAYS ONLY. In the event a landlord, homeowner, or Real Estate agent wishes to connect utilities for a limited time to enable cleanup/moving/etc., nonrefundable fee of $30.00 will be collected, payable at time of application. Proof of ownership or right to admittance to the property must be presented upon application, along with a valid photo ID. The connection will be for a maximum of 10 days and will be discontinued at the end of that period, unless requested for earlier cut by the customer. This will not included garbage service unless requested by the customer (which will result in an additional fee of $19.00). No deposit will be required for this service, unless the time needed extends beyond the 10 day period, at which time a deposit will be required to maintain service. A billing (mailing) address, other than the connection address, must be supplied on this application. If there are any additional charges other than minimum water or water/sewer (2,000 gallons), the charges will be billed to the address supplied and ore subject to all other utility provisions provided for in the City Ordinance.
38. 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.

    1. I agree.
40. Electronic Signature*
41. Date*
    Date
43. Electronic Signature
    Applicant #2 (if applicable)
44. Date
    Date
46. Funding Requirements for our USDA Loans require that we collect ethnicity information to document Nondiscrimination.
48. Race
49. Ethnicity

    1. Non-Hispanic
    2. Hispanic
50. Gender

    1. Male
    2. Female
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