New Submission

Have you had service with the City of Fayetteville in the past or have it now?*field type radio button
Have you had service with the City of Fayetteville in the past or have it now?YesNo

	Requested Service Start Date*field type date	Service Address*field type multi line
row 1	Requested Service Start Date*field type date	Service Address*field type multi line Input blocked. Maximum character limit of 500 characters reached.

	Is Mailing Address Different?field type radio button	*field type multi line
row 1	Is Mailing Address Different?field type radio button Is Mailing Address Different?NoYes	*field type multi line Mailing / Forwarding Address

	Primary Applicant*field type single line	First and Middle Name*field type single line	SS# / Fed ID*field type single line
row 1	Primary Applicant*field type single line Last Name / Business Name Input blocked. Maximum character limit of 60 characters reached.	First and Middle Name*field type single line Input blocked. Maximum character limit of 60 characters reached.	SS# / Fed ID*field type single line Input blocked. Maximum character limit of 4000 characters reached.

	Email*field type email	DL#*field type single line	State*field type single line
row 1	Email*field type email	DL#*field type single line Input blocked. Maximum character limit of 40 characters reached.	State*field type single line Input blocked. Maximum character limit of 4000 characters reached.

	Mobile Phone*field type single line	Secondary Phonefield type single line
row 1	Mobile Phone*field type single line Input blocked. Maximum character limit of 20 characters reached.	Secondary Phonefield type single line Home, Work, etc. Input blocked. Maximum character limit of 20 characters reached.

File Upload - Driver's License Copy*field type file upload
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	Property Ownership*field type radio button	Landlord*field type single line	Phone*field type single line
row 1	Property Ownership*field type radio button Property OwnershipRentOwn	Landlord*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Phone*field type single line Input blocked. Maximum character limit of 4000 characters reached.

File Upload - Lease Agreement (or Utility Sheet for Lindsey Management)field type file upload
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	Secondary Residentfield type single line	SS#field type single line
row 1	Secondary Residentfield type single line Input blocked. Maximum character limit of 4000 characters reached.	SS#field type single line Input blocked. Maximum character limit of 4000 characters reached.

	Secondary Contactfield type single line	Phonefield type single line
row 1	Secondary Contactfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phonefield type single line Input blocked. Maximum character limit of 4000 characters reached.

A Minimum deposit of $50.00 for Residential accounts and $100.00 for Non-Residential/Commercial accounts are required and must be paid prior to utility services being established, set up and activated.

If you are a previous customer and your required deposit amount is higher than the minimum amount, you will be notified in your application confirmation email that an additional deposit amount is required to establish service and the due date the additional deposit amount is due.

If you are a contractor setting up service to set a meter for construction or if you are a landlord setting up service for a rental property, a deposit is not required.

Once you submit your application the link to pay your deposit online will be provided.

By checking the I accept checkbox – you understand that if you are required to pay a deposit – the minimum deposit amount must be paid before service is established.
Minimum Deposit Requirement*field type checkbox
Minimum Deposit RequirementI accept
Submission of this form will not be allowed if you do not indicate that you accept the deposit requirements
This service agreement and deposit is to guarantee the due payment of any indebtedness for any city service due the City of Fayetteville, Arkansas. This deposit shall be retained in escrow, without interest by the City of Fayetteville, Arkansas, It is expressly understood by the undersigned customer that all or any part of this deposit may to the extent necessary be applied by the City of Fayetteville at anytime in satisfaction of said guarantee. The undersigned customer also agrees to comply with all rules and regulations governing city services now in effect or those that may be hereafter established by the City of Fayetteville, Arkansas. When service to the above customer at the stated address is permanently discontinued, and payment of all amounts due the City of Fayetteville are cleared, said service deposit shall be applied to the final billing and remainder, if any, returned to the depositor.
Customer Signature*field type signature Date*field type date
row 1 Customer Signature*field type signature
Date*field type date
Add

	Customer Signature*field type signature	Date*field type date
row 1	Customer Signature*field type signature	Date*field type date

field type radio button
(OPTIONAL) Bank Draft Authorization field type radio button
YESNO
Add
I hereby authorize the City of Fayetteville to bank draft my checking account for payment of my monthly water/sewer/sanitation bills. I understand this authority shall remain in full force and effect until written notification of termination is received from me and the City of Fayetteville has a reasonable oppportunity to process my cancellation request. I understand that nothing contained in this Authorization shall serve to reduce my obligation to pay my City of Fayetteville utility bill and that services may be disconnected should I fail to have sufficient funds in my designated account to cover the amount of the bill. Should my draft be dishonored by my financial institution the City of Fayetteville will no longer allow me to have drafts. I further understand that the name on the bank account to be drafted is the name that appears on my utility account.
A voided check that will represent the account that is to be drafted must accompany this form.
File Upload - Voided Check Copy*field type file upload
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Customer Notesfield type multi line

CITY OF FAYETTEVILLE

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