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2. Owner Name*
3. State*
5. Service Address*
6. Mailing Address (if different than Service Address)
8. Phone #'s*
9. Emergency Phone (In case of a water leak on your property)*
11. Email Address*
12. Would you prefer paperless billing?*

    1. Yes
    2. No
14. Type*

    1. Residential
    2. Commercial
16. If Commercial, please list the following:
18. Manager's Name
19. Phone
21. Will this be a rental property?*

    1. Yes
    2. No
22. Is this home New or Existing?*

    1. New
    2. Existing
23. Date of Closing:
25. Service Requested*

    1. Water
    2. Garbage
    3. Recycle
26. How many garbage/ recycling cans do you currently have?
    (Please specify the type and number of each.)
28. Do you require the removal of recycling/ garbage cans?
    (Please specify the type and number of cans to be removed.)
29. Do you require additional garbage/ recycling cans?
    (Please specify the type and number of cans to be delivered.)
31. Online Bill Payment
    After you have received your first monthly utility bill you may sign up for online bill pay by visiting xpressbillpay.com.
33. Disclaimer & Signature
    I hereby represent that I am the owner of the above mentioned property and wish to apply for the City of North Salt Lake utility services. I agree to abide by all pertinent ordinances and regulations of the City. I agree to pay, when due, the established charges for such services whether supplied to myself, tenant or other occupant. I further agree to be responsible for any garbage collection containers furnished by the City of North Salt Lake. I agree that the City may shut off the water for failure to pay for the charges when due, and that if a turn off is made, all arrears for service, including turn off and turn on charges, shall be paid in full before service is restored. In the event action is required to enforce this agreement, I agree to pay all costs including late fees, collection costs, and reasonable attorney's fees.
    
    Your electronic signature below indicates your agreement with the following statement: By typing my name in the following box and clicking the submit button I certify the information provided on the application is accurate and true.
35. Applicant Signature*
36. Date
    Date
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field