TODAY'S DATE
□ Own □ Rent
ZIP
ZIP
SOCIAL SECURITY / EIN #
NO
NO
Start
Stop
$150 DEPOSIT REQUIRED
LOCATION ADDRESS (METER SITE)
WATER/ SEWER/ STREET
SWEEPING UTILITIES
SIGNATURE TO START SERVICE
X
SIGNATURE TO STOP SERVICE
X
LANDLORD'S PHONE
LANDLORD'S NAME
PRIMARY PHONE
APPLICANT'S NAME
WOULD YOU LIKE TO ENROLL IN AUTO PAY? If Yes, Please Provide Documentation
YES
YES
WOULD YOU LIKE TO RECEIVE YOUR UTILITY BILL ELECTRONICALLY VIA E-MAIL?
E-MAIL ADDRESS
Payment Options Available: www.hollister.ca.gov & (833)-208-7230
Utility bills, including service and penalty charges, are due and payable upon presentation. They are delinquent if not paid on or before the "Due Date" printed on front of the Utility
Service Bill. A 10% penalty is assessed to past due balances.
If your account is past due, shut-off notices are mailed by the 20th of the month. Shut-off will be the 2nd Wednesday of every month. If over-due payments are not received in our
office or in the drop box by 4:30pm on the due date there will be an additional $25.00 delinquent fee assessed. The past due amount plus the delinquent fee must be paid no later than
Tuesday by 4:30pm to avoid water shut-off Wednesday morning. If we do not receive payment before 2:00pm on Wednesday water service will not be reconnected until the following
business day. If you are not able to pay this bill within the required time frame, you must contact the Payment Center during office hours.
REVIEW SCAN FILE
SERVICE PERSON (INTERNAL)
DATE (INTERNAL)
City of Hollister
327 Fifth Street
Hollister, CA 95023
831-636-4301
ACCOUNT NO
Date: .
SECONDARY PHONE
D.O.B.
DRIVER'S LICENSE #
MAILING ADDRESS
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