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2. Application Date*
   Application Date
3. Service Date*
   Service Date
5. Applicant Information
7. Management Company Name
9. First Name*
10. Last Name*
11. SSN/Tax ID *
13. Drivers License/State*
14. Date of Birth
15. Email*
17. Primary Phone*
18. Secondary Phone
20. Service Location Information
22. Type of Account*

    1. New Account

    1. Irrigation Account
24. Service Address*
25. Mailing Address
    If different from service address
27. 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 re connection fees.
29. 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. I (applicant) understand that under this agreement that I will be given notice by the City of Bullard of all delinquencies on this account.
31. 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.
33. Applicant Signature*
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field