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2. PROPERTY OWNER(S) INFORMATION:
4. Property Owner(s) First & Last Name(s):*
6. Email Address:*
7. Phone Number(s):*
9. Service Address:*
11. City*
12. State*
13. Zip Code*
15. Mailing Address:*
17. City*
18. State*
19. Zip Code*
21. REQUESTED SERVICE START-UP DATE:*
23. Garbage Roll Off Cart Size*

    1. 35 Gallon
    2. 65 Gallon
    3. 95 Gallon
24. Recycling Roll Off Cart Size*

    1. 65 Gallon
    2. 95 Gallon
26. TERMS & CONDITIONS:*

    The undersigned, being the property owner of the above described property and account, does hereby request services for city utilities, which includes, but is not limited to, water, sewer, sanitation, stormwater, and streetlights, to be activated and provided to the above described service address.
    
    I/we do hereby acknowledge that I/we have been advised, and I/we agree, that /we will remain legally responsible and liable for unpaid account balances for utility services, as provided by Title 5 of Moscow City Code, assessed against the service address, regardless of who uses the service. I/we further acknowledge that the City may pursue any available legal remedies for nonpayment of any and all unpaid balances due for utility services, including but not limited to discontinuing utility services and placing a lien on the real property to secure all amounts due.
    
    ANY UNPAID BALANCES ARE THE RESPONSIBILTY OF THE PROPERTY OWNER. SERVICES MAY BE DISCONTINUED FOR NON-PAYMENT AND WILL NOT BE REACTIVATED UNTIL THE UNPAID BALANCE IS PAID IN FULL. LIENS MAY BE PLACED ON THE PROPERTY FOR NON-PAYMENT.
    
    I certify under penalty of perjury pursuant to the law of the State of Idaho, that the foregoing is true and correct and that I am the property owner and/or have the authority to bind Property Owner to the terms of this application.
    
    

    1. I HAVE READ AND AGREE TO THE ABOVE TERMS & CONDITIONS
28. ELECTRONIC SIGNATURE AGREEMENT:*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
    
    

    1. I AGREE
30. Signed:*
31. Dated:*
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

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