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2. 
3. Application for New Utility Services
   
   1. Completed, dated and signed service application.
   2. Proof of ownership/authorization (HUD, final settlement statement, warranty deed or valid lease/rental agreement).
   3. Copy of valid applicant's government-issued identification; such as state drivers license, passport, etc.
   4. Deposit amounts are as follows (customer service will call you for payment):
   

   • $50.00 Water Deposit (3/4" Connection)
   • $50.00 Sewer Deposit (3/4" Connection)
   • $30.00 Non-Refundable Service Fee

            $130.00 Total to initiate new service
5. PLEASE NOTE:
   All paperwork and deposits must be in our office by 3pm on date requested to start service.
7. Application Date:*
   Application Date:
8. Start Date:*
   Start Date:
   Please Note: Start date cannot precede application date, nor can Start Date occur on a weekend or holiday.
10. Utility Service Request Type*

    1. Residential

    1. Commercial

    1. Own/Purchased

    1. Rent
12. Address for New Service:*
14. Residence*

    1. Full-Time Residence
    2. Part-Time Residence
16. Is Mailing Address different than Service Address?*

    1. Yes

    1. No
18. Mailing Street*
20. Mailing City*
21. Mailing State
    -- Select One --AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
22. Mailing Zip*
24. Has the City of West Melbourne provided services to you before?*

    1. Yes

    1. No
26. First Name*
27. Last Name*
29. Previous Street Address*
31. ACCOUNT CONTACT INFORMATION
33. Account Name (Name/Business the account is going under)*
35. Contact Name (if not the same as above)
37. Home Phone
38. Mobile Phone
40. Email Address
42. Would you like to receive paperless billing to the email address above?*

    1. Yes

    1. No
44. Are you interested in automatic withdrawals from your bank account?*

    1. Yes

    1. No
46. If you selected YES to automatic withdrawals, we will email you a form to fill out to the email provided above on the day we set up your new service.
50. Customer Acknowledgment
    I (applicant) hereby request the City of West Melbourne to provide utility services at the above service location. I (applicant) agree to pay all charges for services rendered as a result of this request. I (applicant) understand and agree that failure to pay any amount due to the City can result in services not be connected/reconnected until such payment has been received.
52. The account must be closed in writing, can be done in person, email, fax or by mailing a signed letter from the account holder(s) requesting to disconnect the water. The deposit will be applied to your final bill. You will receive a final bill with either a refund or a balance due. If a balance is due, please pay promptly.
    
    NO PHONE REQUESTS WILL BE ACCEPTED!
54. Applicant Signature (Type your name here as signature)*
56. File Upload
    Please upload your proof of ownership/authorization as listed above.
58. Additional File Upload*
    Upload a copy of your photo identification here.
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

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