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2. 
4. Application For Utility Services
6. Customer Information

   Please complete the required customer information necessary to establish service.

8. Applicant Name*
   (First Last)
9. Please select one of the following:*

   1. Owner

   1. Renter
11. Mailing Address*
13. Applicant Primary Phone Number*
14. Applicant Secondary Phone Number
16. Applicant Email Address
18. Would you like to be added to the Village's email list?

    Receive important alerts and news from the Village of Channnahon. 

    Email addresses are shared with the current refuse service provider for their communications.

    1. Yes
    2. No
19. Would you like to enroll in paperless billing?

    If you selected Yes, you would NOT receive a physical bill in the mail. The utility bill would be sent to the email address listed above.

    1. Yes
    2. No
21. Applicant's Previous Address
    (City, State, Zip)
23. Name, Address & Phone Number of Property Owner/Landlord

    If different from applicant.

27. What utility services are you applying for? Check all that apply*

    1. Water
    2. Sewer
    3. Refuse
29. WATER RATES

    $6.93/1,000 gallons usage fee | $5.00 per Account Charge

30. SEWER RATES

    $8.38/1,000 gallons usage fee

31. REFUSE RATES

    $21.94/mo. | $65.82/qtr. | Refuse prices includes $1.00 admin fee

33. PLEASE CHECK ALL STATEMENTS THAT APPLY:

    1. One of the heads of household is 65 or older. Please apply the Senior Discount rate on refuse. (Must provide documentation. Village staff will follow up with you for this information)
    2. One of the heads of household is a 100% disabled veteran. Please apply the 100% Disabled Veteran rate on refuse (Must provide documentation. Village staff will follow up with you for this information)
35. REFUSE SERVICE - NEW CONSTRUCTION

    Refuse service is provided by Environmental Recycling & Disposal. They offer a number of sizing options for refuse, recycling and yard waste carts. The price is the same regardless of the cart size. Yard waste carts are only offered in 95-gallon carts. Please select your refuse and recycling cart sizes below.

    1. REFUSE: 95-gallon
    2. REFUSE: 65-gallon
    3. REFUSE: 35-gallon
    4. RECYCLING: 95-gallon

    1. RECYCLING: 65-gallon
    2. YARD WASTE: Yes
    3. YARD WASTE: No
36. REFUSE SERVICE - EXISTING HOMES

    To change carts, request additional carts or for cart replacement, please contact Environmental Recycling & Disposal directly at www.envrd.com/channahon, or call (815)725-4555.

40. 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.
42. 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 suspended or terminated 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.
44. I do hereby request that service be commenced on:*
    I do hereby request that service be commenced on:
45. At the following service/street address:*
46. Do you also reside at this address?*

    1. Yes
    2. No
48. 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.
50. 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.
52. Electronic Signature*
53. Date*
    Date
55. IMPORTANT: THIS FORM MUST BE RETURNED TO OUR OFFICE WITHIN 10 DAYS TO AVOID INTERRUPTION IN SERVICES.
59. 
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field