REQUIRED DEPOSIT FOR REQUESTED SERVICES: Online Utility Exchange Service is utilized to determine if an account will require a deposit.
SERVICE START DATE: SERVICE ADDRESS: APT/UNIT#:
APPLICANT: DOB: DL#: SSN#:
STATE:
EMAIL ADDRESS: MOBILE PHONE: RECEIVE TEXT MESSAGING: HOME PHONE:
( ) YES NO ( )
MAILING ADDRESS (IF DIFFERENCT FROM SERVICE ADDRESS: CITY: STATE: ZIP:
I WOULD LIKE TO RECEIVE MY BILL VIA EMAIL: YES NO EMAIL ADDRESS:
EMPLOYER: WORK PHONE: PREVIOUS ACCOUNT: PREVIOUS ADDRESS:
( ) YES NO
PERSONAL REFERENCE: PHONE:
CO-APPLICANT INFORMATION (if applicable) DOB: DL#: SSN#:
STATE:
EMAIL ADDRESS: MOBILE PHONE: HOME PHONE:
( ) ( )
EMPLOYER: WORK PHONE: PREVIOUS ACCOUNT: ADDRESS:
( ) YES NO
I/We have read and understand the Customer Service Contract Acknowledgement and hereby agree to abide by the terms and conditions as set forth
by the City of Kerrville.
APPLICANT'S SIGNATURE:______________________________________ CO-APPLICANT'S SIGNATURE:____________________________________________
DATE APPLICATION SIGNED:________/________/__________
EACH APPLICANT MUST PROVIDE A VALID COPY OF THEIR DRIVER'S LICENSE.
APPLICANTS APPLYING FOR SERVICE AT ANY RENTAL/LEASE PROPERTY MUST PROVIDE A COPY OF THEIR LEASE AGREEMENT.
LANDLORD NAME: ADDRESS: PHONE:
( )
EMAIL ADDRESS: TYPE OF PROPERTY: RENT: LEASE: OWN:
RIGHT OF CONFIDENTALITY:
Each applicant hereby confirms their desire to keep their account information confidential.
Applicant INITIAL:_________________ Co-Applicant INITIAL:_________________
DEPOSIT IF REQUIRED: $100.00
NEW ACCOUNT FEE(S): CUSTOMER HAS BEEN NOTIFIED OF THE ONE-TIME ACCOUNT FEE(S) OPTIONS FOR EACH SERVICE. INITIAL:_______________
NEW ACCOUNT FEE: $40.00 EACH ACCOUNT NEW ACCOUNT FEE WITH E-BILL OPTION: $25.00 EACH ACCOUNT
NEW ACCOUNT FEE WITH AUTO-PAY AND E-BILL OPTION: $20.00 EACH ACCOUNT
AUTO-PAY OPTIONS: BANK DRAFT OR CREDIT CARD
BANK DRAFT/CREDIT CARD OPTION: RETURNED ITEM FEE ON ALL RETURNED ITEMS: $30.00. CUSTOMER INITIAL:_______________
IT IS THE CUSTOMERS RESPONSIBILITY TO MAINTAIN AND UPDATE BANKING AND CREDIT CARD INFORMATION.
The City of Kerrville Utility Billing Office hours are Monday through Friday from 8am - 5pm. When requesting your service date, please select a date that falls on a
weekday. We normally offer same day service for all requests if submitted prior to 12pm. However; we appreciate as much advance notice as possible.
CITY OF KERRVILLE REPRESENTATIVE SIGNATURE:_______________________________________________________________
SERVICE REQUIREMENT INFORMATION
CO-APPLICANT INFORMATION (if applicable)
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