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2. DAVE LOWERY

   ^MAYOR

   CHRIS LIGHTFOOT

   ^{INTERIM CITY MANAGER} 

   AMY MYERS

   ^{CITY ATTORNEY}

3. 

4. COMMISSIONERS 

   SAM PEEBLES 

   PAT PERNO 

   JAMIE WARRICK 

   JUDY TINDER

6. REQUEST FOR NEW SERVICE

   $150 REFUNDABLE DEPOSIT & NON REFUNDABLE CONNECTION FEES

    $50.00 PER METER (INSIDE CITY LIMITS) & $62.50 PER METER (OUTSIDE CITY LIMITS)

   When we receive your completed form, we will contact you to collect payment of the deposit and service fee(s).

8. Account Owner's Name*
9. Date to Turn On*
   Date to Turn On

   Business hours only M-F

11. Secondary Owner's Name (if applicable)
13. Service Address (Please include APT # if applicable)*
15. City*
16. State*
17. Zip Code*
19. Mailing Address (Please include APT # if applicable)*
21. City*
22. State*
23. Zip Code*
25. Phone Number*
26. E-Mail Address*
28. Would you like to enroll in phone notifications?*

    1. Yes
    2. No
29. Would you like to enroll in E-mail notifications?*

    1. Yes
    2. No
31. Turn on the Irrigation meter if applicable?*

    1. Yes

    1. No

    Additional Connection fee of $50.00 (Inside City Limits) or $62.50 (Outside City Limits). All irrigation systems are required to have a RPZ type of backflow device installed before we can unlock the meter for use. Failure to comply does not waive the applicable fee

33. Would you like to enroll in paperless billing?*

    1. Yes

    1. No
35. Request a second garbage can for an additional charge?*

    Residential Garbage: 90 gallon can already included. Delivery fee of $25.00 for extra and/or replacement can.

    1. Yes
    2. No
36. Enroll in our Senior Garbage Rate?*

    Must be 65+ and have two or less occupants

    1. Enroll
    2. Not Applicable
38. Drivers License (Primary owner)*
39. Drivers License (Secondary Owner)

    Must be provided if name is listed above.

41. Do you own the property or are you leasing?*

    1. Own
    2. Lease
43. Rental Agreement or Deposit Hold Form

    This is required if you do not own the property.

45. Comments:
47. Agreement

    I HAVE READ AND UNDERSTAND THAT BY SIGNING BELOW, I AGREE TO THE FOLLOWING:

    If an incorrect address is given above, there will be an additional water connection fee for each corrected meter. The city cannot turn on an irrigation meter unless it has a backflow device installed. Failure to comply does not waive the applicable fee. The FDEP has mandated that all irrigations be equipped with a certified backflow protection assembly. It is the responsibility of the homeowner to ensure the backflow preventer is recertified every two years and maintained in good working order, in accordance with the FDEP rule 62-555.360. Failure to have the correct assembly installed will result in termination of irrigation service.

    I assume all responsibility for this account whether I reside at this address or not. I understand that in order to disconnect services I must complete and submit an account closure request form.

    All faucets at the address must be in the off position before water services are turned on. The City shall not be held liable, and the account holder hereby releases the City from any damages due to the account holder's negligence. The City collects your Social Security number for the following purposes: classification of accounts; customer identification and verification; credit worthiness; customer billing and payments; benefit processing, tax reporting and any other lawful purpose necessary to conduct City business. Social Security numbers are NOT public records, but may be released to other governmental or commercial entities as required by law Section 119.071(5), Florida Statues.

49. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    When we receive your completed form, we will contact you to collect payment of the deposit and service fee(s).

    
    

    1. I agree.
51. Electronic Signature*
52. Date:*
    Date:
54. Secondary Electronic Signature

    Required if name is provided above,

55. Date:
    Date:
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field