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 opt out of the Telehealth Services Program? The Village of Algonquin’s Telehealth Services Program allows residents to text licensed Illinois physicians for everyday medical questions, prescription requests, and basic work or school notes for a $6 monthly fee.
YesNo
Would you like to enroll in auto-pay?
YesNo
You will be directed to the auto-pay form after you click Submit
Should be Empty:

Village of Algonquin