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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