Utility App

Application Date:

Primary Applicant Name:
Responsible for all account decisions SS Number:

Primary Address:

Mailing Address: (If Different)

Email Address: (Rwuired)

Primary Phone: Secondary Phone:

Employer: Work Phone:

2nd Applicant Name:
SS Number:

(Spouse or other responsible adult in the household, also responsible for decisions regarding this account)

Employer: Work Phone:

Emergency Contact: Phone:

Is the service address:

Owned

Rented If rented, enter landlord’s name:

Have you or any other occupant at this address ever had an account with the utility?

If YES, please enter the address:
If NO, please initial:

Applying for Following Services (check all that apply)

Electric Water & Sewer Garbage Residential Other:

Payment for utility charges incurred at this service location are the responsibility of the applicant(s) listed below. In case of any action, or court to collect any sums payable hereunder, applicant agrees to pay reasonable attorney fees and collection cost. THIS APPLICATION MUST BE COMPLETED IN FULL AND DEPOSIT PAID BEFORE SERVICE IS PROVIDED. ANY FINAL BILLS LEFT UNPAID WILL BE SUBMITTED TO THE IOWA SETOFF PROGRAM FOR COLLECTION.

(Primary Applicant Signature)

(Secondary Applicant Signature)

Office use only

Approve: Account #: Electric Dept: Water Dept:

Deposit Amount: Payment Method: Date Payed: