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Application for City Services

2. Date
   Date

4. This application is hereby made for water service to be supplied by meter measurements on a monthly basis from the City's mains to the following property.

   This application is hereby made for water service to be supplied by meter measurements on a monthly basis from the City's mains to the following property.

6. Address of Property Needing Service

8. 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.

10. Name*

11. Social Security Number*

    Please fill in your social security number

13. Spouse's Name

14. Spouse's Social Security Number*

    Please fill in your spouse's social security number

16. Mailing Address*

18. Phone*

19. Work Phone

21. Employer*

23. Employer's Address*

25. Spouse's Employer

27. Owner of Property*

29. Date Wanting Service Turned On*
    Date Wanting Service Turned On

31. Service Charge: New Customer
    $50

    $50

32. Transfer Customer
    $15

    $15

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field