APPLICATION FOR CITY OF FAYETTEVILLE UTILITY SERVICES
2914369532
Effective Date
Account Number
Sewer Avg
Sequence Number
Meter Reading
Trans To/From Acct#
Deposit Type and Amount
Service Address
Office Use Only
Office Use Only
Intials
Date
Turn On
Transfer On
New Account
Final Apply
Force Off
Transfer Off
Correct Acc
Deposit Att
No Deposit
Bank Draft
Date to Draft
Requested Service
Start Date
Last First Middle
SS#
ST
YES
(Optional) Bank Draft Authorization:
I hereby authorize the City of Fayetteville to bank draft my checking account for payment of my monthly
water/sewer/sanitation bills. I understand this authority shall remain in full force and effect until written notification
of termination is received from me and the City of Fayetteville has a reasonable oppportunity to process my
cancellation request. I understand that nothing contained in this Authorization shall serve to reduce my obligation to
pay my City of Fayetteville utility bill and that services may be disconnected should I fail to have sufficient funds in
my designated account to cover the amount of the bill. Should my draft be dishonored by my financial institution the
City of Fayetteville will no longer allow me to have drafts. I further understand that the name on the bank account
to be drafted is the name that appears on my utility account. A voided check that will represent the account
that is to be drafted must accompany this form.
NO
Customer Signature Date
SS#
Phone
Rent Landlord Phone
This service agreement and deposit is to guarantee the due payment of any indebtedness for any city service due the
City of Fayetteville, Arkansas. This deposit shall be retained in escrow, without interest by the City of Fayetteville,
Arkansas. It is expressly understood by the undersigned customer that all or any part of this deposit may to the
extent necessary be applied by the City of Fayetteville at anytime in satisfaction of said guarantee. The undersigned
customer also agrees to comply with all rules and regulations governing city services now in effect or those that may
be hereafter established by the City of Fayetteville, Arkansas. When service to the above customer at the stated
address is permanently discontinued, and payment of all amounts due the City of Fayetteville are cleared, said service
deposit shall be applied to the final billing and remainder, if any, returned to the depositor.
Checking Savings
Own
Service Address
Mailing Address
(if Different)
Primary Resident
Email
Business Name
(if Commercial)
DL#
Cell Phone
Secondary Resident
Secondary Contact
Fed ID
Contact Phone
Employed By
W/O#
click to sign
signature
click to edit
![]()
