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Application for New Utility Services
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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
PLEASE NOTE:
All paperwork and deposits must be in our office by 3pm on date requested to start service.
Application Date:
*
Application Date:
Start Date:
*
Start Date:
Please Note: Start date cannot precede application date, nor can Start Date occur on a weekend or holiday.
Utility Service Request Type
*
Residential
Commercial
Own/Purchased
Rent
Address for New Service:
*
Residence
*
Full-Time Residence
Part-Time Residence
Is Mailing Address different than Service Address?
*
Yes
No
Mailing Street
*
Mailing City
*
Mailing State
-- Select One --
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Mailing Zip
*
Has the City of West Melbourne provided services to you before?
*
Yes
No
First Name
*
Last Name
*
Previous Street Address
*
ACCOUNT CONTACT INFORMATION
Account Name (Name/Business the account is going under)
*
Contact Name (if not the same as above)
Home Phone
Mobile Phone
Email Address
Would you like to receive paperless billing to the email address above?
*
Yes
No
Are you interested in automatic withdrawals from your bank account?
*
Yes
No
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.
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.
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!
Applicant Signature (Type your name here as signature)
*
File Upload
Please upload your proof of ownership/authorization as listed above.
Additional File Upload
*
Upload a copy of your photo identification here.
Leave This Blank:
Receive an email copy of this form.
Email address
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