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2. Application for Utility Services
4. Deposit:
   Sewer/Trash - $65.00 Water/Sewer/Trash - $115.00 ($25.00 Water turn on fee/ $90 deposit) Trash Only - $25.00 Sewer Only - $65.00 Commercial Accts - $250.00
6. Services Applying For: *

   1. Sewer/Trash
   2. Water/Sewer/Trash
   3. Trash Only

   1. Sewer Only
   2. Commercial Account
8. Name*
9. Spouse*
11. Service Address
13. Address1*
15. Address2
17. City*
18. State*
19. Zip*
21. Mailing Address
    (If different than service address)
23. Address1
25. Address2
27. City
28. State
29. Zip
31. Home Number*
32. Cell Number*
34. Email address*
36. Date of Birth*
38. Driver's License Number *
39. State*
41. Social Security Number*
43. Place of Employment*
44. Work Number*
46. Service Start Date*
50. Senior Citizen Discount
    There is a 10% discount on sanitation services for seniors 65 and older. Please supply the utility department with a copy of your state issued identification to qualify.
52. Note:
    Payments are due by the 10th of each month. Deposits will be returned after 12 consecutive months of on time payments. Returned checks / NSF electronic draft will be subject to a $25.00 fee.
54. Sewer Customers with Goforth Water
    If you receive your water bill from Goforth Water Supply Company, you can submit your water bills for the months of November, December, January & February to us each year to calculate your sewer bill for the next year. If you do not submit those bills you will be charged based on 7,000 gallons of water usage to calculate your sewer.
58. Garbage Service (check all that apply)*

    1. 90 gallon cart already at residence
    2. Order 90 gallon cart PLUS recycle bin
    3. Order recycle bin only

    1. Recycle bin already at residence
    2. Order 90 gallon cart only
    3. None
60. Terms of Acceptance*

    1. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
62. Account
63. Meter Count
64. Subdivion
66. Date Paid Deposit
67. Method of Payment
68. Service Start Date
70. Services

    1. Water
    2. Sewer
    3. Trash
71. TDS Contact Date
72. Staff Initals
Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field