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New Non-Residential Customer Application

2. 
4. NON-RESIDENTIAL UTILITY SERVICE AGREEMENT
6. Street Address (Meter Location)
8. Billing Address
10. ACCOUNT INFORMATION
12. Business Name/DBA
13. Requesting Service Start Date
15. First Name
16. Middle
17. Last Name
19. I am the business:

    1. Owner
    2. Authorized Representative
21. Sales Tax Exempt

    1. Yes (must provide certificate)
    2. No
23. Business Owner's Address
25. Owner's Phone Number
26. Business Phone
27. Preferred Contact Method

    1. Phone
    2. Email
29. Primary Contact E-Mail Address
31. EMERGENCY & SECONDARY CONTACTS
33. First Name
34. Last Name
35. Phone
37. First Name
38. Last Name
39. Phone
41. MAINTENANCE CONTACTS
43. First Name
44. Last Name
45. Phone
47. First Name
48. Last Name
49. Phone
51. Please list and special instructions regarding security protocol:
53. AGREEMENT SIGNATURE
55. Electronic Signature Agreement

    I acknowledge that all High Strength Wastewater customers must request a pretreatment questionnaire form. This document is to be filled out by the appropriate commercial/industrial personnel upon the signing of this service agreement. Furthermore, I understand the pretreatment questionnaire must be returned to the Director of Public Works within thirty days of the initiation of sewer service so the City of Republic can determine if appropriate surcharges for biochemical oxygen demand (BOD), phosphorus (P) and total suspended solids (TSS) are necessary. I agree to abide by all of the City of Republic ordinances regarding water and sewer services and state that all of the information contained on both sides of this service agreement is true and accurate as of this date.

    1. I agree.
57. Electronic Signature
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field