Residential Water Service Application

2. Address*

3. Apt #

5. Mailing address

7. City

8. State

9. Zip

11. First Name*

12. Last Name*

14. driver's license/id*

15. date of birth*

16. phone number*

18. email address

20. Place of employment and phone number

22. co-applicant's first name

23. co-applicant's last name

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

26. co-applicant's date of birth

27. co-applicant's phone number

29. co-applicant's email address

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

33. Landlord's name

34. Landlord's phone number

36. Account Confidentiality*

    1. yes
    2. no

38. 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.

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39. 1. Receive email copy
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field