CITY OF HARRISONBURG
APPLICATION FOR UTILITY SERVICES
2155 Beery Rd
Harrisonburg VA 22801
540-434-9959
540-434-9769 fax
Residents requiring water, sewer, and trash service may complete this service application online and forward it to the City of
Harrisonburg/Public Utilities at the above address or submit via email to WaterService@harrisonburgva.gov. All applications must
be submitted along with a letter of credit or security deposit, which will be applied to your account upon receipt of (12) twelve
consecutive on time payments, or refunded upon account closure ,(we reserve the right to apply deposit as final payment as
necessary). The City of Harrisonburg does not pay interest on deposits. For questions or details please visit www.harrisonburgva.gov.
The City of Harrisonburg Public Utilities conducts business in accordance with the City Ordinance (Title 7 Chapters 1-5).
DO NOT WRITE ABOVE THIS LINE ACCOUNT NUMBER: _______________________________
PLEASE PRINT
NAME: _______________________________________________ __________________________________________ _________
LAST FIRST MI
SERVICE ADDRESS: _________________________________________________SERVICE START DATE: ___________________
Check One:
MAILING ADDRESS: __________________________________________ __________________________ _________ _____________
(IF DIFFERENT) CITY STATE ZIP
HOME PHONE: WORK PHONE: _________________________________________
CELL PHONE: __________________________________________ ALT PHONE: __________________________________________
DATE OF BIRTH: ________________________________________ LAST 4 OF SSN: _______________________________________
___________________________________________ __________ _____________
DRIVERS LICENSE NUMBER STATE EXPIRATION
Passport / (Government Issued ID): ___________________________________________________ Exp: _____________
EMPLOYER:_________________________________________________________
PERMISSION TO DISCUSS ACCOUNT WITH: ______________________________________________________________________
FOR
INTERNET / ONLINE PAYMENT OPTION AND AUTOMATIC PAYMENT DRAFT:
PAPERLESS BILLING: EMAIL ADDRESS:
Check Box:
PIN #: ___________________________________ (4 to 8 alphanumeric digits)
** FOR OFFICE USE ONLY**
DEPOSIT PAID $___________CK#__________CASH
LANDLORD Y OR N
JMU UDAP NUMBER: __________________________
OWNER
TENANT
LANDLORD
PROPERTY MANAGER
Y
AUTOMATIC PAYMENT DRAFT:
Check Box:
ROUTING NUMBER: _________________ BANK ACCOUNT NUMBER: __________________________
I understand that I am responsible for collection and legal costs associated with pursuit of any delinquent account. I further recognize that
to provide a forwarding address upon termination of service may avoid the above costs.
I hereby consent to the jurisdiction of the courts of Rockingham County over any action filed against me for the collection of my account.
The undersigned agrees and recognizes that by signature they enter into contract bound by City Ordinance Title 7 Chapters1-5 and are obligated to
monthly payments.
SIGNATURE: ____________________________________________________________ DATE: ______________________________
H:\Sherri\FORMS & LETTERS\Application for Utilitiy Services-Individual.NEW.doc
CHECKING
SAVINGS NOTE: ACH CANCELLATION REQUIRES NOTICE 10 DAYS IN ADVANCE
