Primary Applicant Name(Required) First Last 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 Home PhoneCell Phone(Required)Email(Required) Employer Employer's PhoneIs there an additional applicant? Yes No Additional Applicant Name(Required) First Last Home PhoneCell Phone(Required)Email(Required) Employer Employer's PhoneConsent(Required)The undersigned hereby agrees that in the event the account becomes delinquent, the application must 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 fees 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.Primary Applicant Electronic Signature (Full Name)(Required) Additional Applicant Electronic Signature (Full Name)(Required) PhoneThis field is for validation purposes and should be left unchanged.
