Form Center

2. City of Le Mars Water Department
   Application for Water Service
   
   
4. Today's Date
   Today's Date
6. Customer Name*
7. Home Phone
8. Cell Phone*
10. Social Security Number*
11. Email Address:*
13. Service Address*
14. Start Service Date
    Start Service Date
16. City*
17. State*
18. Zip*
20. Billing Address (If Applicable)
22. City
23. State
24. Zip
26. Property Ownership*

    1. Rent
    2. Own
27. Name of Landlord and Phone Number / Purchased From (if owned)*
29. I hereby apply for utility services for the premises listed above pursuant to the rules of the utilities. I agree to pay for all bills provided to me by the City of Le Mars. If I fail to pay utility bills on a timely basis, I understand that utility services may be discontinued and reconnect fees apply. I further agree to give prior notice to the City of Le Mars of my intent to discontinue utility services and agree to pay my final bill promptly and in full. I understand that I will not be allowed utility service at a new Le Mars address if I am delinquent at a previous Le Mars address until the previous bill is paid in full.
31. 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.

    1. I agree.
33. Electronic Signature*
34. Date
    Date
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field