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2. City of Belleview Utilities
4. NEW CUSTOMER CONNECTION FORM
   Please note: You will need to verify your identity with a state issued ID and a copy of your Lease/Rent/Purchase Agreement. THE NEW CUSTOMER CONNECTION FORM, IDENTIFICATION AND LEASE/RENT/PURCHASE AGREEMENT MUST ALL BE IN THE SAME NAME.
6. First Name*
7. Last Name*
9. New Service Address*
10. Phone Number*
12. City
13. State
14. Zip Code
18. Mailing Address (If Different from Sevice Address)
20. City
21. State
22. Zip Code
26. Email Address
28. E-Bill Registration

    1. E-bill via Email

    By checking here, I am agreeing to receive electronic copies of my bill via email and do not wish to receive paper copies of said bill.
29. I Prefer a Paper Bill

    1. Paper Bill Preference

    By checking this box, I would like to receive paper bills mailed to my mailing address and the email address I provide may only be used for communication in reference to my account set up.
33. Easy Account Access
    Easy Account Access will enable us to verify your identity so that we can make changes to your account over the telephone such as: address changes, disconnection of service and vacation leaves.
35. Choose a Security Question
    -- Select One --Mother's Maiden Name?First Child's Name?Favorite Color?First Pet's Name?

    This passcode will be used to verify your authority to make changes to your account information.
36. PASSCODE:
    Answer to the selected Security Question.
40. Late Penalty
    Bills not paid by 6:00 PM on the 15th of the month, or the first business day after the 15th should the 15th fall on a Friday, the weekend, or holiday, will automatically have an additional 10% Late Penalty applied.
42. Non-Payment Status
    Bills not paid by 6:00 pm on the 30th of the month, or the first business day after should the 30th day of the month fall on a Friday, the weekend, or holiday, will render the account to be in Non-payment Status and a Non-payment Status Penalty of $60.00 will be automatically applied to the account. Service may be discontinued if bill is not paid.
44. New Account Set Up Time Frame
    If new account is set up and deposit and connection fees are paid before noon, water will be turned on the same day. If account set up is completed after noon, the water will be turned on the next day. Customer MUST be present when water is turned on. City is not responsible for any leaks or running water on customer side of meter.
46. New meter installations may take up to two weeks to install. Installation can only be done if the area for the new meter is clear and technicians can get to the area to install the meter. Customer is required to "Call Before You Dig" and have gas, electric, cable, dog/pet, etc. buried lines marked (please do that immediately). The City is not responsible for lines such as these being cut during meter installation.
48. New Customer Information Brochure
    New Customer Information Brochure

    Please read the attached brochure.

50. Acknowledgement
    I have reviewed the completed application and all information is correct to the best of my knowledge. I agree to claim no damages due to the stoppage of water or sewage flow caused by accident or by the necessity of making alterations, repairs, or improvements. By signing below, I acknowledge that I have reviewed my customer information brochure from the City of Belleview. I understand the billing procedures and policies explained within the brochure.
52. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
54. Electronic Signature*
55. Application Date*
    Application Date
56. Service Turn On Date*
    Service Turn On Date
58. Documents Required
    Documents verifying your identity and access to the property for which you are requesting services are necessary to process your application. After receiving your application and the necessary documents, the City will contact you to complete your service connection. Deposit and Connection fees are required prior to connecting you to services.
60. Legible Copy of ID*
    Please provide a legible copy of your state issued ID.
61. Copy of Lease/Rental/Purchase Agreement - PDF, TIF, DOC, PNG, JPG Formats ONLY*

    Please provide a copy of the document granting you occupancy of the residence for which you are requesting service. NOTE: Agreements are likely to be multiple pages. Documents sent as a JPEG or GIF will open as a one-page picture. It is necessary to provide the page that confirms your rights to the property (Name and service address on same page) and the signature page. If sending as separate pictures, you may use the extra document fields below.

63. Additional Document, if needed
64. Additional Document, if needed
66. Additional Document, if needed
67. Additional Document, if needed
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field