Service Application
Home Up Water Quality Report Service Application



City of Wolfforth




Account #: ___________________________           Start Date:  ___________________________


Primary Acct Name:  __________________________________________________________


DOB:  ______________________________    SS#:  __________________________________


Driver�s Lic. #: ___________________        ____   State:  _________________________________


Street Address ________________________________________________________________


Mailing Address (if different) ____________________________________________________


Home #:  ____________________________            Cell #:  ________________________________


Work #:  ____________________________            Employer: _____________________________


Email address:  ________________________________________________________________




Secondary Acct Name:  _________________________________________________________


DOB:  ______________________________ SS#:  _________________________________


Driver�s Lic. #:  ______________________ State:  ________________________________


Email address:  ________________________________________________________________


Responsible Party:     Yes      No                   Sprinkler System:       YES     NO


                The City of Wolfforth is requested to furnish utility service at the above address and the undersigned agrees to pay for such services at the rate prescribed by the City of Wolfforth until such time as the undersigned gives notice to discontinue service.              

                Utility bills are due on the 10th of each month.  Accounts that remain unpaid after the 20th of each month are assessed a $20 service fee and may be disconnected.    The city may discontinue service absolutely without additional notice until arrears shall be paid.  Courtesy second notices are by telephone only.  A charge will be made on returned checks.

                I/we will abide by and consider part of this contract any ordinances, rules and regulations the city adopts concerning the City Utility Department.

                We will now have the ability to email bills, so if you would like to have it emailed to you, we will need you to provide a current and accurate email address.



Signature _______________________________________________________________________


Deposit Paid:  $100.00           cash ______            check ______          credit card _______



PRIVACY of information:                                                                     How to Bill you:


Confidential   ________         Non-Confidential _______                     Print                        Email                       Both



A current phone number is necessary to let you know information such as:

v  Water disconnection date for non-payment (second notices)

v  Street paving or construction

v  Water emergencies or repairs

v  Disruption in garbage service

v  Other City business