CITY OF BYRON - RESIDENTIAL UTILITY APPLICATION

Residential Utility Application

City of Byron
You must provide the following information to be eligible for service activation.
US issued identification.

2MB max - Please compress your file if needed.
Cancelof
Lease/Renters Agreement/Settlement Statement/Warranty Deed

2MB max - Please compress your file if needed.
Cancelof
Date Service Begins

MonthDayYear
Date
Name

First NameLast Name
DOB

MonthDayYear
Date
SSN
Drivers License # DL#* and State IssuedState issued*
Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Receive Text Notifications?
Email
example@example.com
Opt-in to Paperless Billing?
How would you like to pay the deposit and application fee?
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Employer Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
Spouse Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Drivers License # blanks* and State Issuedblank*
Spouse SS#
Spouse DOB

MonthDayYear
Date
Spouse's Employer Name
Spouse's Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Rent or Own?
Signature
Date

MonthDayYear
Date
Please verify that you are human
FOR CITY OF BYRON USE ONLY
Amount Paid
Payment Type
Receipt #
Should be Empty:

Residential Utility Application

You must provide the following information to be eligible for service activation.