VOA Water Service Application

Village of Algonquin

Service Application
Status
Customer Name*
Date of Birth

MonthDayYear
Phone Number*
E-mail*
By submitting this form, you consent to receive electronic communications from the Village of Algonquin.
OwnerTenant/Renter
Owner Name*
Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Start Date*

MonthDayYear
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Same as service address
Would you like to enroll in auto-pay?
Enroll in Autopay*

YesNo
You will be directed to the auto-pay form after you click Submit
Text A Physician Program Information

Starting service with the Village enrolls you in the Text A Physician telehealth program. This optional service allows residents to text licensed Illinois physicians for everyday medical questions and prescription requests for a $6 monthly fee assessed on your monthly water and sewer utility bill.

You can learn more about the program, including details on how to opt out, by visiting: https://www.algonquin.org/telehealth

Note: The link above opens in a new window.
Should be Empty:

Village of Algonquin