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Yes No Additional Applicant Name(Required) First Last Home PhoneCell Phone(Required)Email(Required) EmployerI would like to round my bill up to the next dollar each month to support the WORKS Roundup Program that aids residents who have faced hardships.(Required)Learn more about the program at waynewhitecoop.com/community Yes No Consent(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)
