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2. This section for office use only

   New Account _____      Transfer Fee _____      Modification_____ 

   Account#: _______-____________-_______ 

   Bad Debt search completed: _____      Application Fee added: _____      

   Deposit Amount: $_______
   

   Water _____      Sanitation _____      Sewer _____      EMS _____      

   Extra Trash Poly Cart _____      Extra Recycling Poly Cart _____      

   Users Fee _____      Water Fee _____      Need Inspection  _____      Service Order Sent  _____      

   Clerk Initials______

   
   

   ***$20.00 APPLICATION FEE WILL APPEAR ON FIRST MONTH’S BILL**

   NOTE: PREVIOUS BALANCES(S) OWED CITY MUST BE PAID IN FULL BEFORE SERVICE CONNECTION

4. Service Address*
6. Property Owner*
8. Name of Applicant(s)*
10. Driver's License Number*
11. Driver's License State *
12. Birth date*
14. Phone number*
15. SSN
17. Mailing Address*
19. Email*
21. Applicant's Employer
23. Occupation
24. Employer Phone #
26. Employer Address
30. Spouse/Occupant 2 Name
32. Driver's License #
33. Birth date
34. Phone Number
36. Spouse/Occupant 2 Employer
38. Occupation
39. Employer Phone #
41. Employer Address
45. Personal Reference*
47. Relationship *
48. Phone #*
50. Address *
54. Have you previously had utility services with the City of Chickasha? *

    1. Yes

    1. No
56. If yes, when?
57. Previous Service Address?
59. I authorize ____ to obtain information on my account.
    This could be a spouse, child, trusted friend or family member, etc. who can access your account information.
61. I authorize ____ to make decisions and/or sign documents for my account.
    This could be a spouse, child, trusted friend or family member, etc. who can make changes to your account.
63. By typing my name (digital signature) below, I agree to pay the established rates set by the City of Chickasha ordinances and agree to regulations governing said services. I understand that this application becomes a contract upon the establishment of services. *
64. Today's date*
    Today's date
68. Service Contract - Residential
70. Service Address*
72. Agreement
    The undersigned, hereafter called the "Applicant", hereby applied to the following service, Water from the City of Chickasha Municipal Authority, hereinafter called the "Authority", with the execution of this application, the Applicant agrees to the terms of this agreements.
74. 1.*

    The Applicant will pay forthwith to this Authority the sum of ($55 for a homeowner, $80 for a renter) as a deposit for the Utility services. Deposit will be retained by the Authority until service is disconnected. Upon the issuance of the final bill, the deposit will be applied to the outstanding charges and the balance, if any remains it will be mailed to the forwarding address on file.

    1. I accept
76. 2.*

    The acceptance of this application by the Authority shall constitute an agreement between the Applicant and the Authority, and the contract for Utility Services shall continue in force form the date of services made available to the Applicant, by the Authority, and thereafter until cancelled by either party.

    1. I accept
78. 3.*

    The Applicant will purchase from and pay the Authority for: Water Service and Refuse Collection charge to be used on the premises described below. The Applicant will pay said bill for services by the due date of each month or pay such penalties and fees as may be assessed by the Authority.

    1. I accept
80. 4. *

    The Applicant will comply with and be bound by the provisions of the regulations of the Authority. If any delinquent account is turned to collections or an attorney, or if suit is filed, all costs and attorney fees associated therewith, fees, costs, and expenses, shall be added to the delinquent account.

    1. I accept
82. 5. *

    Applicant hereby agrees to furnish the information as required by the Authority. Any information found to be false or not supplied, hereby beeches the contract and the above said services can be terminated at the option of the City of Chickasha Municipal Authority.

    1. I accept
84. File Upload - Lease Agreement/Proof of Ownership*

    Upload one of the following documents: a copy of your lease agreement (renters) or proof of ownership (homeowners).

85. File Upload - Government-Issued ID*

    Upload a copy of your valid, government-issued ID

Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

* indicates a required field