Fillable Instructions: 1. Complete this two-sided application in its (City of Veneta)

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Instructions: 1. Complete this two-sided application in its (City of Veneta)

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The Instructions: 1. Complete this two-sided application in its (City of Veneta) form is 2 pages long and contains:

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  • 9 check-boxes
  • 45 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Veneta

BROWSE CITY OF VENETA (OR) FORMS

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Instructions: 1. Complete this two-sided application in its entirety; read statement; sign application (front and back).
2. Submit application to City by one of the following methods:
a) In person: to 88184 8th Street, Veneta. b) Mail to: P.O. Box 458, Veneta OR 97487
3. Appear in person with a least one piece of government issued, photo-bearing identification.
4. Pay a $70.00 deposit.
Type of Use: (mark one) Residence Business Other
Status: (mark one) Owner Tenant
Mailing Address (if different from service address): Mailing Address (if different from applicant's):
Last 4-digits of Social Security #: Last 4-digits of Social Security #:
Month and Year of Birth: Month and Year of Birth:
Phone Numbers: Home: Phone Numbers: Home:
Current Employer's Name: Current Employer's Name:
Employer's Phone #: Employer's Phone #:
Full Name of Persons (18 years old or older) Living with You: Full Name of Persons (18 years old or older) Living with You:
Have you had service with the City of Veneta previously? Have you had service with the City of Veneta previously?
Yes No If so, provide the following: Yes No If so, provide the following:
Previous Veneta Service Address: Previous Veneta Service Address:
Name on Account (if different than above): Name on Account (if different than above):
Applicant's Signature:
Date:
Co-Applicant's Signature: Date:
Applicant's Information
Co-Applicant's Information
Full Name: (First, Middle, Last)
Full Name: (First, Middle, Last)
By My/Our Signature Below I/We affirm that we are at least 18 years old and affirm under penalty for false swearing the accuracy of the
information provided on this application and other information requested; I/We agree to abide by the Veneta Municipal Code and rules
and regulations adopted in regards to the provision of water, sewer, storm-water drainage, and other services.
Alternate #:
Alternate #:
Utility Account and
Service Application
Account Information
Service Address:
Service Beginning Date:
PO Box 458 * Veneta, OR 97487 * 541-935-2191 * Fax 541-935-1838 * www.venetaoregon.gov
S:\FORMS\Utility Billing\Utility Account and Service Application
Applicants must be 18 years of age or older to open an account with the City (per ORS 109.510 & 653.10.4)
4/24/2020
Home: Other:
Rental agreement provided*
Property Owner agreement on file*
Unpaid balance on service address
Deposit Paid
Application complete
Application signed (front and back)
Identity checked and confirmed 18 yrs of age or older
Unpaid balance on applicant (Search UB system for Last Name)
Application Approved Yes No If no, why?
Once approved: Scan Application Owner Agreement
Attach to UB account Application Owner Agreement
Signature of Property Owner
Date
Email:
I, (print name) ___________________________________________________ and ______________________________________________ are
the owner(s) of the property for which City services are being requested. I guarantee that if the applicant fails to make payments in accordance with
the rules, regulations and ordinances of the City of Veneta, I will pay such arrearages and be liable for those charges, including any penalties and
interest accrued. I further agree the City may lien my property, identified above, in the amount of any unpaid utility bills.
Signature of Property Owner
APPLICATION CONTINUED ON BACK
Signature of Property Owner
Date
The City of Veneta does not discriminate on the basis of race, color, religion, sex, national origin, age or mental and/or physical disability.
FOR CITY STAFF USE ONLY
I, (print name) ___________________________________________________ and ______________________________________________ are
the owner(s) of the property for which City services are being requested. I guarantee that if I fail to make payments in accordance with the rules,
regulations and ordinances of the City of Veneta, I will pay such arrearages and be liable for those charges, including any penalties and interest
accrued. I further agree the City may lien my property, identified above, in the amount of any unpaid utility bills.
Signature of Property Owner
Date
IF UTILITY ACCOUNT WILL BE IN THE PROPERTY OWNER'S NAME: Sign the following:
Date
IF UTILITY ACCOUNT WILL BE IN A TENANT'S NAME:
Phone Numbers:
Property Owner Name (s):
Mailing Address:
PROPERTY OWNER MUST FILL OUT ONE OF THE BOXES BELOW IN ORDER FOR THE CITY TO
PROCESS AND APPROVE THIS APPLICATION
S:\FORMS\Utility Billing\Utility Account and Service Application
4/24/2020
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Instructions: 1. Complete this two-sided application in its (City of Veneta)

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Completed 10 March 2021

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