Business Name(Required) Applicant Name(Required) First Last Title Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Business Phone(Required)Business FaxCell Phone(Required)Cell PhoneConsent(Required)The undersigned hereby agrees that in the event the account becomes delinquent, the applicant shall pay, in addition to the account balance, all costs of collection, reasonable attorney fees, and other costs incurred by the City of Fairfield in connection with the collection of the balance due for utility services rendered. If any false or fraudulent information is provided by an applicant, the City of Fairfield retains the right to immediately disconnect utilities upon discovery of presentation of false information. By signing below, I acknowledge that I have read and received a copy of this application regarding the nonrefundable connection fee by the City of Fairfield. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required) EmailThis field is for validation purposes and should be left unchanged.
