CITY OF CANFIELD
104 LISBON ST
CANFIELD, OH 44406
330-533-1101 PHONE
330-533-2668 FAX
www.ci.canfield.oh.us
RETURN COMPLETED APPLICATION TO:
CITY OF CANFIELD
104 LISBON ST
CANFIELD, OH 44406
WATER@CI.CANFIELD.OH.US
FAX: 330-533-2688
Book: _____________________________________
Account: __________________________________
Entered by:________________________________
AGREEMENT FOR WATER/SEWER SERVICE
SERVICE ADDRESS INFORMATION
Applicant Type: Owner Rental (If renting, please provide owner information below)
Previously lived in the City of Canfield? YES NO
Requested Service Start Date: ______________
____________________________________________ ___________________________________ ____________ ___________________
LAST NAME FIRST NAME MIDDLE
_________________________________________________________________________ ________________________ __________
ADDRESS CITY ZIP
____________________________________ _____________________________________ _____________________________________________
PHONE ALTERNATE PHONE EMAIL ADDRESS
____________________________________ _____________________________________ _____________________________________________
DATE OF BIRTH EMPLOYER DRIVER LICENSE NUMBER STATE
OWNER INFORMATION (if rental)
____________________________________ ___________________________________ ___________________
LAST NAME FIRST NAME MIDDLE
_________________________________________________________________________ ________________________ __________
ADDRESS CITY ZIP
____________________________________ _____________________________________ _____________________________________________
PHONE ALTERNATE PHONE EMAIL ADDRESS
The City of Canfield will send the utility bill to either the owner of the property or the occupant of the property, please indicate who should receive the
utility bill. If the billing address is different than the addresses provided above please indicate the appropriate billing address.
UTILITY BILL SHOULD BE SENT TO: Owner Occupant Other (please fill out appropriate information below)
____________________________________________ __________________________________ _________ ___________________
LAST NAME FIRST NAME MIDDLE
_________________________________________________________________________ ________________________ __________
ADDRESS CITY ZIP
I (WE) THE UNDERSIGNED APPLICANT(S) FOR WATER AND/OR SEWER UTILITY SERVICE, UNDERSTAND THE TERMS AND CONDITIONS OF SUCH
SERVICES AS PRESCRIBED IN THE CODIFIED ORDINANCES OF THE CITY OF CANFIELD AND AGREE TO ABIDE BY SAID PROVISIONS.
_____________________________________________________ ______________________________
Applicant Signature Date
_____________________________________________________ ______________________________
Applicant Signature Date
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