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Application for City Services

2. Today's Date*
   Today's Date

3. Date to start NEW Service*
   Date to start NEW Service

5. Address of Property Needing Service*

7. Is this a RENTAL PROPERTY? *

   Answer YES or NO

8. Rental Property Owner (if applicable)

10. APPLICANT INFORMATION

12. Name*

14. Current Street Address*

16. Mailing Address (if it will be different than Service Address)

18. Phone Number*

19. E-mail Address*

21. Date of Birth*

22. Social Security Number*

23. Drivers License Number*

25. Employer*

27. Employer's Address*

29. SPOUSE/ PARTNER LIVING AT NEW PROPERTY

31. Name

33. Phone Number

34. E-mail Address

36. Date of Birth

37. Spouse's Social Security Number

38. Drivers License Number

40. This application is an exclusive contract between the City of Clearwater, Sedgwick County, Kansas, and the applicant at the above address. The applicant agrees to be responsible for all payments for water, sewer, and trash services at the above address from the date service under this application is commenced until service is terminated by notice.<br><br>The applicant agrees to abide by the established ordinances, rules and regulations pertaining to services of the City of Clearwater, Kansas, now in force or which may be enacted or adopted and to pay for services at the regular established rates, by 5 p.m. on or before the 10th of each month.<br><br>If the bill is not paid by 5 p.m. on or before the 10th of each month, a 10% penalty charge will be assessed on the net water/sewer/trash bill and a shut off notice will be sent on the 15th of the month.

    This application is an exclusive contract between the City of Clearwater, Sedgwick County, Kansas, and the applicant at the above address. The applicant agrees to be responsible for all payments for water, sewer, and trash services at the above address from the date service under this application is commenced until service is terminated by notice.
    
    The applicant agrees to abide by the established ordinances, rules and regulations pertaining to services of the City of Clearwater, Kansas, now in force or which may be enacted or adopted and to pay for services at the regular established rates, by 5 p.m. on or before the 10th of each month.
    
    If the bill is not paid by 5 p.m. on or before the 10th of each month, a 10% penalty charge will be assessed on the net water/sewer/trash bill and a shut off notice will be sent on the 15th of the month.

42. New Customer Connection Fee
    $50

    $50

43. Transfer from one Property to Another Fee
    $15

    $15

Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

* indicates a required field