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2. Date of Application*
3. Date of Service*
5. Applicant Information
7. Business Name*
8. Tax I.D.*
10. Contact Information
12. Contact Name*
13. Contact Phone Number*
15. Driver License Number/State*
16. Contact Email *
18. New Service Location Information
20. Please check all that Apply

    1. New Account
    2. Irrigation Account

    1. Transfer Account
    2. Own Property

    1. Renting Property
22. Service Address*
23. Mailing Address (If different)
25. If Renting
27. Landlord Name
28. Landlord Phone Number
30. If Transferring

    A $25.00 service fee will be added to the new account.

32. Current Service Address*
33. Current Account Number
35. Date to terminate current Account*
37. Trash Services*

    *Please note that trash services are $32.96 plus tax which includes one poly cart. Additional poly carts are $7.30 plus tax and will be added to your monthly bill.

39. About your Deposits
    The City of Bullard requires that every utility customer pay a deposit upon opening or re-establishing an account with the city to guarantee payment on the account for water, sewer, and solid waste services rendered. A deposit is required for every location served by the City. Therefore, customers with more than one utility account are required to provide a deposit for each account up to a certain amount. A customer pays the deposit with the express understanding and agreement that the City may apply all or any part of the deposit towards an arrearage on the account in satisfaction of the amount owed. Deposits are funded to the customer upon closing an account. The City will refun the deposit less any amount owed to the City. The refund is paid by check and is mailed within 30-60 days of the final meter reading on the account. The customer is responsible for providing the forwarding address to the City.
41. Disconnection Policy
    The City of Bullard utility services are subject to disconnection on the 1st of the month for non-payment, accrual of 10% late payment charge and reconnection fees.
43. Agreement
    I (applicant) hereby request the City of Bullard to provide utility services at the above location. I (applicant) agree to pay all charges for services rendered as a result of this request. I (applicant) understand and agree that failure to pay any amount due to the City can result in services not being connected/reconnected until such payment has been received.
45. 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.
47. Applicant Signature*
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field