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Application For Utility Services

2. 

4. Application For Utility Services

6. I do hereby request that service be commenced on:*
   I do hereby request that service be commenced on:

8. At the following service/street address:*

9. Do you also reside at this address?*

   1. Yes
   2. No

11. Check all that apply*

    1. Water
    2. Sewer
    3. Refuse (choose tote size below)

13. I understand that according to village ordinance, I am responsible for prompt payment of any charges incurred on my account. I further understand that if payment is not received on my account or if any other policy is violated, my services may be terminated upon notice by the Village of Channahon and I would be responsible for any and all payments for reconnection fees, collection fees, and court costs incurred by the Village of Channahon as a result of this matter.

    I understand that according to village ordinance, I am responsible for prompt payment of any charges incurred on my account. I further understand that if payment is not received on my account or if any other policy is violated, my services may be terminated upon notice by the Village of Channahon and I would be responsible for any and all payments for reconnection fees, collection fees, and court costs incurred by the Village of Channahon as a result of this matter.

15. I have read and agree to the following statements above.*

    1. I agree

18. The following information is required of applicants to establish service:

20. First Name of Applicant*

21. Last Name of Applicant*

23. Please select one of the following:*

    1. Owner

    1. Renter

25. Service Address*

27. City*

28. State*

29. Zip Code*

31. Mailing Address*

33. City*

34. State*

35. Zip Code*

37. Applicant Phone Number*

38. Applicant Work Phone Number

40. Applicant Email Address

41. Name of Employer/Position

45. *PLEASE FILL OUT THE FOLLOWING INFORMATION IF DIFFERENT FROM APPLICANT*
    Contact Information for Property Owner of Service Address

    Contact Information for Property Owner of Service Address

47. Name

48. Phone Number

50. Address

52. City

53. State

54. Zip Code

56. Applicant's Previous Address

58. City

59. State

60. Zip Code

62. Residential and commercial accounts, including all multi-family dwellings on Village water supply, are billed on a monthly basis. Refuse only accounts are billed on a quarterly basis. Bills are due and payable within thirty (30) days of billing date. Unpaid accounts will incur a late charge of 10% per month based on the unpaid balance. Water, sewer, and refuse rates are subject to change by Village Board action. Current rates are as follows:

    Residential and commercial accounts, including all multi-family dwellings on Village water supply, are billed on a monthly basis. Refuse only accounts are billed on a quarterly basis. Bills are due and payable within thirty (30) days of billing date. Unpaid accounts will incur a late charge of 10% per month based on the unpaid balance. Water, sewer, and refuse rates are subject to change by Village Board action. Current rates are as follows:

64. WATER (WA) RATES:
    $6.22/1,000 gallons usage fee

    $6.22/1,000 gallons usage fee

65. SEWER (SW) RATES:
    $7.67/1,000 gallons usage fee $5.00 per Account Charge

    $7.67/1,000 gallons usage fee $5.00 per Account Charge

67. Refuse-Choose One:

    1. 35 gal. tote $17.13/mo. $51.39/qtr.

    1. 64 gal. tote $19.05/mo. $57.15/qtr.

    1. 96 gal. tote $20.86/mo. $62.58/qtr

69. PLEASE CHECK WHICH STATEMENT(S) APPLY:

    1. Existing home – previous owner left cart.
    2. Existing home – previous owner left cart but is the wrong size.
    3. New home – cart needs to be delivered.

    1. Existing home – cart needs to be delivered.
    2. Need 64 gal. recycle tote
    3. One of the heads of household is 65 or older. Please give me my Senior Discount on my Refuse.

71. I have read and understand the provisions of this application and agree to abide by the provisions of such service as provided in the Village of Channahon Code of Ordinances.

73. 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.
75. Electronic Signature*

76. Date*
    Date

78. IMPORTANT: THIS FORM MUST BE RETURNED TO OUR OFFICE WITHIN 10 DAYS TO AVOID INTERRUPTION IN SERVICES.

80. rev 07.18.2019

    rev 07.18.2019

Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field