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2. I am requesting services as of the following date (weekdays only):
   I am requesting services as of the following date (weekdays only):
4. First Name*
5. Last Name*
7. Email Address
9. Service Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
17. Mailing Address

    1. My mailing address is different from my service address
19. Mailing Address*
21. City*
22. State*
23. Zip Code*
25. Upload Picture or Copy of Valid ID (State Issued ID or Passport)*
29. Ownership Status*
    -- Select One --I rent the propertyI own the property
31. Deposit type

    1. I will provide my Social Security Number and pay a $125 deposit
    2. I do not have/do not want to provide my Social Security Number. $175 deposit
    3. Commercial Deposit: $200

    Renters are required to pay a fully refundable deposit. Deposits are refunded at account closing less any amount owed. Please select one of the above options.

33. Social Security Number
37. Demographic Information
    The Town's utility systems are funded in part by federal loans and grants that require the Town to collect and report demographic information about our customers to ensure services are being provided in a non-discriminatory fashion.
39. Gender
    -- Select One --MaleFemale
40. Race
    -- Select One --American Indian/Alaskan NativeAsianBlack/African AmericanHawaiian/Other Pacific IslanderWhite
41. Ethnicity
    -- Select One --Hispanic or LatinoNot Hispanic or Latino
45. Service Agreement

    The account holder agrees to pay their monthly bill by the 20th of each month. If not paid on or before the 20th of the month a 10% penalty will apply. If payment is still not received on or before the 4th of the following month, service will be subject to disconnection on the 5th of that following month. An administrative fee of $25 will apply when service is disconnected due to non-payment. The administrative fee, plus the past due amount must be paid before service is restored. Insufficient funds will result in a $25 fee. All fees and rates are subject to change by the Dobson Board of Commissioners. Tampering with meters or backflow devices, or violating ordinances related to water and sewer utilities may result in service termination. The account holder will be liable for any balance on the account until the account is terminated in writing by the account holder. The Town of Dobson may release information to collection services who may charge additional collection fees to account holder. The Town of Dobson is an equal opportunity provider.

47. Signature
    By typing your name you hereby agree to the above service agreement.
48. Date
    Date
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field