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2. Service Start Date*
   Service Start Date
3. Owner / Renter*
   -- Select One --OwnerRenter
5. First Name*
6. Last Name*
8. First Name
9. Last Name
11. Service Address 1*
13. Service Address 2
15. City*
16. State*
17. Zip*
21. Mailing Address*
    -- Select One --YesNo

    If your Mailing Address is the same as the Service Address listed above, please select 'Yes.' Otherwise, please select 'No' and complete the remaining fields.

23. Mailing Address 1
25. Mailing Address 2
27. City
28. State
29. ZIP
33. Mobile Phone 1*
34. Mobile Phone 2
35. Home Phone
36. Work Phone
38. Email*
42. Account Number*
    -- Select One --NoYes

    If you would like the Account Number emailed to you once created, please select 'Yes.'     Otherwise, please select 'No.'

43. Account Setup Fee
    Sec. 14-63

    Per Code Sec. 14-63, a $10.00 Account Setup Fee will be applied to the first bill. 

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 Submit and Print

* indicates a required field