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Utilities Service Application

Step 1 of 1

The applicant swears that all the information provided by them in this application is true and correct and understands that false or misleading information shall be cause for the Town to deny or cancel service and demand immediate payments of any accounts which are due.

Please fill out the application below to apply for utilities service.

THIS FORM DOES NOT SIGN YOU UP FOR WATER SERVICE. FORMS NEED TO BE BROUGHT INTO THE OFFICE WITH PHOTO ID.

PLEASE BRING YOUR SETTLEMENT STATEMENT OR LEASE INTO THE OFFICE TO SIGN UP FOR WATER SERVICE.

* Denotes a required field

Date*

MonthDay Year,

Name(s)*

Drivers License Number*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Landlord Information (signed rental agreement/lease/contract required)

Landlord Name*

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Any other authorized person on the account?

Yes No

Please Do Not Complete The Following Field

If so, name

Phone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Relationship to account holder

Please click submit when finished.

Utilities Service Application

Landlord Information (signed rental agreement/lease/contract required)

Dialog Title