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2. Change Effective Date*
3. Account Number*
5. Service Address*
7. Type of Change*

   1. Mailing Address

   1. Name Change
9. Information About You
11. First Name*
12. Last Name*
13. Last Four Digits of Social*
15. Primary Phone*
16. Secondary Phone
18. Email*
20. Address*
22. Documentation Provided*

    1. Marriage License

    1. Divorce Decree

    1. Court Order for Name Change

    1. Entity Name Change Document

    Please scan in or take a picture of document and email it to utilities@bullardtexas.net
24. 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.
26. Account Holder Signature
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field