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2. Today's Date*
   Today's Date
3. Date to start NEW Service*
   Date to start NEW Service

   Date you will be wanting the new services to start at the new address.

4. Date to STOP OLD Service*
   Date to STOP OLD Service

   Date you are wanting to stop services at the old address you will be moving from.

6. Address of Property Needing New Services*
8. Is this a RENTAL PROPERTY? *
   Answer YES or NO
9. Rental Property Owner (if applicable)
11. APPLICANT INFORMATION
13. Name*
15. Address of Property Needing to Discontinue Services*
17. Mailing Address (if it will be different than Service Address)
19. Phone Number*
20. E-mail Address*
22. Date of Birth*
23. Employer*
25. Employer's Address*
27. Sign up for E-Statements?*

    Answer Yes or No

28. E-Mail Address
30. CONTACT FROM CITY HALL

    City Hall will contact you via Phone Number on this form to complete application.

32. SPOUSE/ PARTNER LIVING AT NEW PROPERTY
34. Name
36. Phone Number
37. E-mail Address
39. Date of Birth

41. 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 14th of each month.

    
    

    If the bill is not paid by 5 p.m. on or before the 14th 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.

43. Connection Fee

    The connection fee is a one time charge and will be added to your first bill. If you are a new customer to Clearwater the fee will be $50.00. If you already have utility services in your name and are moving to a new home your fee will be $15.00.

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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

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