Service Address - Street, Apt/Ste

Requested Service Start Date (no weekends, holidays or backdated start service dates):

Business Name:

Owner/Corporate Officer Name:

Mailing Address - Street, Apt/Ste

Mailing Address - City, State, Zip Code

Primary Phone:

E-mail:

ID - Document Number

City Business License Number:

I DECLARE UNDER PENALTY OF PERJURY THAT 1) I AM THE RESPONSIBLE PARTY AT THE SERVICE ADDRESS AND/OR AN AUTHORIZED REPRESENTATIVE OF THE BUSINESS, AND 2) THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT. I ACCEPT RESPONSIBILITY FOR THIS UTILITY SERVICE AND AGREE TO ABIDE BY ALL RULES AND REGULATIONS ESTABLISHED BY THE CITY COUNCIL GOVERNING UTILITIES.