Utility Service Form
265 Strand Street, St. Helens, OR 97051 | 503-397-6272 | www.sthelensoregon.gov
Applicant Name(s): ________________________________________________________________________________________________
Location of Premise Served: ________________________________________________________________ Lot #: ___________________
Mailing Address (If Different): _______________________________________________________________________________________
Phone Number: _______________________ Email: _______________________________________________
Alternate Phone Number: ___________________
Date: _______________________
Applicant's Drivers License State/Number: _________________________________
Co-Applicant's Drivers License State/Number: _______________________________
Date Service Requested (m/d/yyyy): _____________________
Applicant Signature: _________________________________________________
Co-Applicant Signature: ______________________________________________
Date: _______________________
ON OFF NEW METER
OWNER/MGR RENTER CONTRACTOR
Water is Currently (Check One):
Applicant is (Check One):
Billing Options (Check O
ne):
PAPER EMAIL BOTH
OWNER ACKNOWLEDGEMENT:
If an applicant is not the owner/manager of the property for which service is being requested, the owner must also
sign the application:
I, ________________________________________ am the owner/manager of the property for which water service is being requested.
If the applicant fails to make payments in accordance with the rules, regulations, and ordinances of the City of St. Helens, I agree to be
liable for those charges. The above information is that of the person on the rental agreement.
Owner/Property Management Mailing Address: ___________________________________________________________
___________________________________________________________
Signature of Owner/Manager: ____________________________________________ Date: ______________________________
Phone Number: _____________________
Deposit Fees: Contractor Processing Fee is $25.00 (non-refundable; new meter only)
OFFICE USE ONLY
Deposit Amount: ____________ Deposit Posted: Cash Card Check
New Account Number: ________________________ Lot #: _____________________
Notify PW by email of new meter install
Add to Suspend List
You can email this form to utilitybilling@ci.st-helens.or.us, or in person at the Utility Billing office located at 275 Strand Street, St. Helens OR 97051
*Copy of ID is required
*Copy of ID is required
