RESIDENTIAL UTILITY APPLICATION FOR THE CITY OF BYRON

Residential Utility Application

City of Byron
Date Service Begins*

MonthDay Year
Date
Name*

First Name Last Name
SSN*
Drivers License # DL#* and State IssuedState issued*
DOB*

MonthDay Year
Date
Service Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Receive Text Notifications?*

YesNo
Email*
example@example.com
Opt in to Paperless Billing?*

YesNo
How would you like to pay the deposit?*

Bill mePay in person
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Name*
Employer Phone #*
Please enter a valid phone number.
Employer Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you have a spouse?*
Spouse Name*

First Name Last Name
Spouse Phone #*
Please enter a valid phone number.
Spouse's Drivers License # blanks* and State Issuedblank*
Spouse SS#*
Spouse DOB*

MonthDay Year
Date
Spouse's Employer Name*
Spouse's Employer Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Spouse's Employer Phone Number*
Please enter a valid phone number.
Emergency Contact Name*

First Name Last Name
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Rent or Own?*

RenterOwner
Signature*

Clear
Date*

MonthDay Year
Date
FOR CITY OF BYRON USE ONLY
Amount Paid
Payment Type
Receipt #
Should be Empty:

Residential Utility Application