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Residential Water Service Application

2. Address*

3. Apt #

5. Mailing address

7. City

8. State

9. Zip

11. Start Date

13. First Name*

14. Last Name*

16. driver's license/id*

17. date of birth*

18. phone number*

20. email address

22. Place of employment and phone number

24. co-applicant's first name

25. co-applicant's last name

27. co-applicant's driver's license/id

28. co-applicant's date of birth

29. co-applicant's phone number

31. co-applicant's email address

33. co-applicant's place of employment and phone number

35. Landlord's name

36. Landlord's phone number

38. Account Confidentiality*

    1. yes
    2. no

40. By submitting this application, you agree to the terms and conditions of city ordinance code 51.037.

    By submitting this application, you agree to the terms and conditions of city ordinance code 51.037.

Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field