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2. First Name*
3. Last Name*
5. Service Address*
7. City*
8. State*
9. Zip Code*
11. Mailing Address
    If different than service address
13. Email*
14. Phone*
15. Phone*

    1. Cell
    2. Home
    3. Work
17. Driver's License No.*
18. State*
19. Date of Birth*
    Date of Birth
21. Employer
25. FOR RENTER'S ONLY
27. Landlord's Name
28. Phone
30. Address
34. CONTRACT
    I hereby request the City of Seaside to supply service as heron, until the receipt of formal notice from me requesting discontinuance of this service. I agree to pay for such service promptly each billing according to the statement shown by the meter at the regular rates applicable for such service as provided in the Rates, Rules, and Regulations of the City of Seaside which have been approved by the City Council
36. 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.
38. Electronic Signature*
39. Date*
    Date
40. Please check one:*

    1. Owner
    2. Real Estate
    3. Renting
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field