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2. Utility Account Number
3. Date*
   Date
4. Tenant Move in Date*
   Tenant Move in Date
6. Service Address*
8. City*
9. State*
10. Zip*
14. In consideration of the acceptance of this application for water and garbage collection service submitted by the stated tenant, I or we will pay for all water and garbage collection services for any such tenant or any other occupant of the stated address, in case such tenant or occupant shall fail to pay for the same according to the ordinances, rules, regulations or resolutions enacted by this municipality.
16. Owner First Name*
17. Owner Last Name*
19. Owner Signature*
21. Owner Phone Number*
22. Other Number
23. Owner Email*
25. Owner Address*
27. City*
28. State*
29. Zip*
33. Tenant First Name*
34. Tenant Last Name*
36. Tenant Email Address
37. Tenant Phone Number*
39. Tenant Mailing Address (if different than service address)
41. City
42. State
43. Zip
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field