Form Center

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. Add Secondary Account Owner

8. Current Account Owner's Name*
10. New Secondary Owner's Name*
12. Customer ID#*
14. Service Address (Please include APT # if applicable)*
16. Mailing Address*
18. Account Owner's Phone Number*
19. Account Owner's E-Mail Address*
21. Secondary Owner's Phone Number*
22. Secondary Owner's Email Address*
24. Would you like to enroll in phone notifications?*

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

    1. Yes
    2. No
27. Would you like to enroll in paperless billing?*

    1. Yes

    1. No
29. Drivers License (Primary owner)*
30. Drivers License (Secondary Owner)*
32. Comments:
34. Agreement

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

    
    

    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. 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 may collect 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.

36. 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.
38. Electronic Signature*
39. Date:*
    Date:
41. Secondary Electronic Signature*
42. Date:*
    Date:
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field