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2. Today's Date*
   Today's Date
3. Date to start NEW Service*
   Date to start NEW Service
5. Address of Property Needing Service*
7. Is this a RENTAL PROPERTY? *
   Answer YES or NO
8. Rental Property Owner (if applicable)
10. APPLICANT INFORMATION
12. Name*
14. Current Street Address*
16. Mailing Address (if it will be different than Service Address)
18. Phone Number*
19. E-mail Address*
21. Date of Birth*
22. Employer*
24. Employer's Address*
26. Sign up for E-Statements?*

    Answer Yes or No

27. E-Mail Address
29. CONTACT FROM CITY HALL

    City Hall will contact you via Phone Number on this form to complete application.

31. SPOUSE/ PARTNER LIVING AT NEW PROPERTY
33. Name
35. Phone Number
36. E-mail Address
38. Date of Birth

40. This application is an exclusive contract between the City of Clearwater, Sedgwick County, Kansas, and the applicant at the above address. The applicant agrees to be responsible for all payments for water, sewer, and trash services at the above address from the date service under this application is commenced until service is terminated by notice.

    
    

    The applicant agrees to abide by the established ordinances, rules and regulations pertaining to services of the City of Clearwater, Kansas, now in force or which may be enacted or adopted and to pay for services at the regular established rates, by 5 p.m. on or before the 10th of each month.

    
    

    If the bill is not paid by 5 p.m. on or before the 14th of each month, a 10% penalty charge will be assessed on the net water/sewer/trash bill and a shut off notice will be sent on the 15th of the month. 

    If the bill is not paid by 5:00 p.m. on or before the 14th of the month, a 10% penalty charge will be assessed on the total bill. The total bill with penalty must be paid by the last day of the month or services will be disconnected. If services are disconnected for non-payment, a $25.00 re-connection fee will be assessed.

42. Connection Fee
    The connection fee is a one time charge and will be added to your first bill. If you are a new customer to Clearwater the fee will be $50.00. If you already have utility services in your name and are moving to a new home you fee will be $15.00.
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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

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