Service Application
Home Up Water Quality Report Service Application

 

 

City of Wolfforth

APPLICATION FOR UTILITY SERVICES

 

 

Account #: ___________________________           Start Date:  ___________________________

 

Primary Acct Name:  __________________________________________________________

 

DOB:  ______________________________    SS#:  __________________________________

 

Driver�s Lic. #: ___________________        ____   State:  _________________________________

 

Street Address ________________________________________________________________

 

Mailing Address (if different) ____________________________________________________

 

Home #:  ____________________________            Cell #:  ________________________________

 

Work #:  ____________________________            Employer: _____________________________

 

Email address:  ________________________________________________________________

 

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Secondary Acct Name:  _________________________________________________________

 

DOB:  ______________________________ SS#:  _________________________________

 

Driver�s Lic. #:  ______________________ State:  ________________________________

 

Email address:  ________________________________________________________________

 

Responsible Party:     Yes      No                   Sprinkler System:       YES     NO

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                The City of Wolfforth is requested to furnish utility service at the above address and the undersigned agrees to pay for such services at the rate prescribed by the City of Wolfforth until such time as the undersigned gives notice to discontinue service.              

                Utility bills are due on the 10th of each month.  Accounts that remain unpaid after the 20th of each month are assessed a $20 service fee and may be disconnected.    The city may discontinue service absolutely without additional notice until arrears shall be paid.  Courtesy second notices are by telephone only.  A charge will be made on returned checks.

                I/we will abide by and consider part of this contract any ordinances, rules and regulations the city adopts concerning the City Utility Department.

                We will now have the ability to email bills, so if you would like to have it emailed to you, we will need you to provide a current and accurate email address.

 

 

Signature _______________________________________________________________________

 

Deposit Paid:  $100.00           cash ______            check ______          credit card _______

 

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PRIVACY of information:                                                                     How to Bill you:

 

Confidential   ________         Non-Confidential _______                     Print                        Email                       Both

 

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A current phone number is necessary to let you know information such as:

v  Water disconnection date for non-payment (second notices)

v  Street paving or construction

v  Water emergencies or repairs

v  Disruption in garbage service

v  Other City business