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2. 
4. RESIDENTIAL UTILITY SERVICE AGREEMENT
6. Street Address*
7. Number In Household*
9. Do You:*

   1. Own Home
   2. Rent Home
10. Do you have an irrigation system?*

    1. Yes
    2. No
11. Do you have pets that bite or display signs of aggression?*

    1. Yes
    2. No
12. If pets are aggressive, is it an outside dog?*

    1. Yes
    2. No
14. When would you like to start service?*
    When would you like to start service?
16. PRIMARY ACCOUNT HOLDER
18. First Name*
19. Middle*
20. Last Name*
22. Birthdate (Month)*
    -- Select One --JanauryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
23. Birthdate (Date)*
    -- Select One --12345678910111213141516171819202122232425262728293031
24. Birthdate (Year)*
    -- Select One --200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910
25. Social Security Number*
27. Driver's License/ID Number*
28. State*
30. Primary Phone Number*
31. E-Mail Address*
32. Preferred Contact Method*

    1. Phone
    2. Email
34. Current Employer*
35. Work Phone*
37. SECONDARY ACCOUNT HOLDER
39. First Name
40. Middle
41. Last Name
43. Birthdate
44. Primary Phone Number
45. E-Mail Address
47. Driver's License Number
48. Driver's License State
49. Social Security Number
51. Current Employer
52. Work Phone
54. EMERGENCY CONTACT
56. Name*
57. Relationship*
58. Phone Number*
62. WASTEWATER SERVICE OPTIONS*

    Choose the following option that you prefer for your summer sewer rate:

    
    

    
    

    1. Submit usage data from your previous utility provider's bill to calculate a November-March sewer average
    2. Set sewer rate avg. based on 1700 gallons/person until such time as the Nov-Mar usage calculation is determined the next year. During Nov-Mar, sewer will be charged based upon metered water usage.
    3. Sign an agreement to be billed a sanitary sewer charged based on metered water usage (sewer usage will match water usage) during the time span of April through October.
66. PRIVACY INFORMATION
68. THIS PORTION OF THE FORM PERTAINS ONLY TO MISSOURI’S “SUNSHINE LAW”. OTHER LAWS OR REGULATIONS MAY REQUIRE THE CITY TO RELEASE INFORMATION CONTAINED IN YOUR FILE TO OTHER GOVERNMENTAL ENTITIES, INCLUDING LAW ENFORCEMENT AGENCIES. I/We understand that if my/our customer service account becomes delinquent for non-payment, it is subject to being turned over for recovery and/or collection. I/We are responsible for payment of all collection and legal costs or fees associated with recovery of any outstanding balance in my/our name(s).*

    Type full name here for signature

70. As a residential customer, do you give permission for any information contained in your utility record file to be released to third parties? Furthermore, do you permit the City of Republic and its business associates to contact you, and all other responsible parties on your account (via cell phone, e-mail, or U.S. Mail), concerning any and all aspects of my account? *

    For YES, please type full name here for signature

74. AGREEMENT SIGNATURE
76. 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. I/We agree to abide by the Republic City Ordinances/Regulations pertaining to utility services; that all the above information is true and accurate; and that I/We are responsible for all billings until written notification is provided to the City to discontinue service.

    1. I agree.
78. Electronic Signature*
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit

* indicates a required field