H:\Sherri\FORMS & LETTERS\Application for Utilitiy Services-Business.doc
CITY OF HARRISONBURG
APPLICATION FOR UTILITY SERVICES
2155 Beery Rd
Harrisonburg VA 22801
540-434-9959
540-434-9769 fax
Businesses 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 at 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. Deposit must be received prior to account set up. 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 OF COMPANY: ____________________________________________________________________________________
SERVICE ADDRESS: _______________________________________________________________________________________
SERVICE START DATE: ____________________________BUSINESS PHONE NUMBER:____________________________
BILLING MAILING ADDRESS: _____________________________________________________________________________
(IF DIFFERENT)
_________________________________________________________________________________
CITY STATE ZIP
OWNER NAME: ___________________________________________________________________________________________
OWNER PHONE NUMBER: ___________________________ALTERNATE PHONE NUMBER: _________________________
FEDERAL TAX ID NUMBER / EIN:__________________________________________________________________________
NAME OF INDIVIDUAL COMPLETING FORM: _____________________________________________________________
Please Print
FOR
INTERNET / ONLINE PAYMENT OPTION:
EMAIL ADDRESS: ___________________________________________________________________________________________________
PIN #: ______________________________ (4 to 8 alphanumeric digits) Paperless Billing:
We understand that we will also be responsible for collection and legal costs associated with pursuit of any delinquent account. We further recognize
that to provide a forwarding address upon termination of service may avoid the above costs.
We hereby consent to the jurisdiction of the courts of Rockingham County over any action filed against us for the collection of our account. The
undersigned agrees and recognizes that by signature they (the above business) enter into contract bound by City Ordinance Title 7 Chapters 1-5 and
are obligated to monthly payments.
SIG
NATURE: DATE: _________________________________
**FOR OFFICE USE ONLY**
DEPOSIT PAID $_________CK#___________CASH
