Application for Utility Services (Water & Garbage)

2. Bluffdale City Utilities Application (Water & Garbage)

4. Billing Name*

   (Must be Home Owner)

5. Additional Name

   (Must be Home Owner)

7. Email Address*

8. Email Address

10. Address Where Services are Requested*

12. Mailing Address (if different)

14. City

15. State

16. Zip

18. Phone Number*

19. Phone Number

21. Purpose of Application:*

    1. New Home
    2. Existing Home
    3. Commercial
    4. Other

22. Date of Closing*
    Date of Closing

23. Proof of Purchase*

    Include proof of Purchase - Closing Statement from the closing documents with name, address & date of closing. NO Real Estate contracts or deeds.

25. 

27. # of Trash Cans*
    -- Select One --123Commercial (no service)Call office for more than three cans

28. # of Recycle Cans*
    -- Select One --123Commercial (no service)Call office for more than three cans

29. # of Green Waste Cans (not required)*
    -- Select One --012Commercial (no service)Call office for more than two cans

31. Set-up Fee

    A set-up fee of $35 will be added to your first billing.

    A set-up fee of $35 will be added to your first billing.

33. License Information & Fee

    I, the undersigned, hereby apply for utility services from Bluffdale City for the above named premises and agree to pay any and all charges incurred for said services (including but not limited to culinary water, storm water, street lights and garbage collection) in accordance with rates fixed by Bluffdale City. Failure to pay my bill in full by the 25th of each month or having an excessive or extended balance, will result in an interruption or disconnection of service(s). I recognize and consent that a reconnection fee of $50.00 will be assessed. Payment in full of all outstanding charges, including the reconnection fee will be required before services can be restored. I agree to be responsible for any damage to the water meter and any other damage pertaining to the service connection. Failure to pay said charges will result in interruption of services. I agree to pay all reasonable attorney fees and other costs incurred by Bluffdale City to obtain collection on this account, whether or not litigation is actually filed.

    I, the undersigned, hereby apply for utility services from Bluffdale City for the above named premises and agree to pay any and all charges incurred for said services (including but not limited to culinary water, storm water, street lights and garbage collection) in accordance with rates fixed by Bluffdale City. Failure to pay my bill in full by the 25th of each month or having an excessive or extended balance, will result in an interruption or disconnection of service(s). I recognize and consent that a reconnection fee of $50.00 will be assessed. Payment in full of all outstanding charges, including the reconnection fee will be required before services can be restored. I agree to be responsible for any damage to the water meter and any other damage pertaining to the service connection. Failure to pay said charges will result in interruption of services. I agree to pay all reasonable attorney fees and other costs incurred by Bluffdale City to obtain collection on this account, whether or not litigation is actually filed.

35. Electronic Signature*

    1. I Agree

    By checking 'I Agree', you agree to acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.

37. Signature*

38. Date*
    Date

40. FOR OFFICE USE ONLY

42. Previous Owner

    __________________________________

    __________________________________

43. Account #

    __________________________________

    __________________________________

44. New Account #

    __________________________________

    __________________________________

46. Meter Reading

    __________________________________

    __________________________________

47. 

48. Date Cans Ordered

    __________________________________

    __________________________________

50. Date Setup

    __________________________________

    __________________________________

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

* indicates a required field